Meditation and Mindfulness Practices for Mental Health: A ... · The material in this report, including selection of articles, summaries, and interpretations is the responsibility

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Evidence Compass

Technical Report

Meditation and Mindfulness Practices for

Mental Health: A Rapid Evidence Assessment

December 2018

Meditation and mindfulness for mental health

Disclaimer

The material in this report, including selection of articles, summaries, and interpretations is the

responsibility of Phoenix Australia - Centre for Posttraumatic Mental Health, and does not

necessarily reflect the views of the Australian Government. Phoenix Australia does not endorse

any particular approach presented here. Readers are advised to consider new evidence arising

post-publication of this review. It is recommended the reader source not only the papers

described here, but other sources of information if they are interested in this area. Other sources

of information, including non-peer reviewed literature or information on websites, were not

included in this review.

© Commonwealth of Australia 2018

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part

may be reproduced by any process without prior written permission from the Commonwealth.

Requests and inquiries concerning reproduction and rights should be addressed to the

publications section, Department of Veterans’ Affairs or emailed to [email protected].

Phoenix Australia Centre for Posttraumatic Mental Health Level 3, 161 Barry Street

Carlton

Victoria, Australia 3053

Phone: (+61 3) 9035 5599

Fax: (+61 3) 9035 5455

Email: [email protected]

Web: www.phoenixaustralia.org

mailto:[email protected]

http://www.phoenixaustralia.org/


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Acknowledgements

This project was funded by the Department of Veterans’ Affairs (DVA). We acknowledge the

work of staff members from Phoenix Australia who were responsible for conducting this project

and preparing this report. These individuals include: Dr Tracey Varker, Dr Julia Fredrickson,

Ms Jessica Gong, Ms Juhi Khatri, Ms Loretta Watson, and Professor Meaghan O’Donnell.

Suggested citation:

Varker, T., Fredrickson, J., Gong, J., Khatri, J., Watson, L. & O’Donnell, M. (2018). Meditation

and mindfulness practices for mental health: A Rapid Evidence Assessment. Report prepared for

the Department of Veterans’ Affairs. Phoenix Australia - Centre for Posttraumatic Mental Health.


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Table of Contents

Acknowledgements ............................................................................................................ 3

Glossary of Terms .............................................................................................................. 6

Executive Summary ............................................................................................................ 8

Introduction ....................................................................................................................... 13

Meditation, mantram meditation, and transcendental meditation ......................................... 13

Yoga ................................................................................................................................... 13

Mindfulness ......................................................................................................................... 14

Therapeutic application of mindfulness ............................................................................... 14

Impactful components of meditation, yoga, and mindfulness............................................... 16

Mechanisms underpinning meditation, yoga, and mindfulness-based interventions ............ 17

Neurophysiological mechanisms ......................................................................................... 17

Psychological and behavioural mechanisms ....................................................................... 18

Meditation, yoga, and mindfulness for PTSD ...................................................................... 21

Meditation, yoga, and mindfulness for depression ............................................................... 22

Meditation, yoga, and mindfulness for anxiety symptoms .................................................... 23

Meditation, yoga, and mindfulness for alcohol use disorder (AUD)...................................... 24

Method ............................................................................................................................... 25

Defining the research question ............................................................................................ 25

Search strategy ................................................................................................................... 26

Search terms ...................................................................................................................... 26

Paper selection: Question 1 Stand-alone meditation and yoga treatments .......................... 28

Paper selection: Question 2 Stand-alone mindfulness treatments ....................................... 29

Paper selection: Question 3 Adjunct meditation, yoga, and mindfulness treatments ........... 30

Information management .................................................................................................... 31

Evaluation of the evidence .................................................................................................. 31

Strength of the evidence base ............................................................................................. 31

Overall strength ................................................................................................................... 33

Direction.............................................................................................................................. 33

Consistency ........................................................................................................................ 33

Generalisability ................................................................................................................... 34

Applicability ......................................................................................................................... 34

Ranking the evidence.......................................................................................................... 35

Results ............................................................................................................................... 36

Identification ........................................................................................................................ 37

Screening ............................................................................................................................ 37

Eligibility .............................................................................................................................. 37

Included .............................................................................................................................. 37

Identification ........................................................................................................................ 38

Screening ............................................................................................................................ 38


Eligibility .............................................................................................................................. 38

Included .............................................................................................................................. 38

Summary of the Evidence ................................................................................................ 39

Stand-alone meditation and yoga treatments ...................................................................... 39

Meditation interventions ...................................................................................................... 39

Yoga interventions .............................................................................................................. 43

Stand-alone mindfulness treatments ................................................................................... 54

Adjunct meditation, yoga and mindfulness treatments ......................................................... 62

Adjunct meditation .............................................................................................................. 62

Adjunct yoga ....................................................................................................................... 62

Adjunct mindfulness ............................................................................................................ 66

Discussion ......................................................................................................................... 69

Stand-alone meditation and yoga treatments ...................................................................... 70

Stand-alone mindfulness treatments ................................................................................... 72

Adjunct meditation, yoga and mindfulness treatments ......................................................... 74

Limitations ......................................................................................................................... 75

Implications ....................................................................................................................... 75

Conclusion ........................................................................................................................ 76

References ........................................................................................................................ 78

Appendix 1 ........................................................................................................................ 89

Population Intervention Comparison Outcome (PICO) framework ....................................... 89

Question 1 .......................................................................................................................... 89

Question 2 .......................................................................................................................... 90

Question 3 .......................................................................................................................... 91

Appendix 2 ........................................................................................................................ 92

Example search strategy ..................................................................................................... 92

Appendix 3 ........................................................................................................................ 93

Quality and bias checklist .................................................................................................... 93

Appendix 4 ........................................................................................................................ 94

Evidence profile: Stand-alone meditation and yoga treatments ........................................... 94

Evidence profile: Stand-alone mindfulness treatments ...................................................... 115

Evidence profile: Adjunct meditation, yoga and mindfulness treatments ........................... 130

Appendix 5 ...................................................................................................................... 142

Evaluation of the evidence ................................................................................................ 142

Appendix 6 ...................................................................................................................... 145

Description of mindfulness-based interventions program curricula .................................... 145

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Glossary of Terms

Term Definition

AC Active control

ACC Anterior cingulate cortex

AD Alcohol dependence

ANS Autonomic nervous system

ASG Alcohol Support Group

ASTM Automatic self-transcending meditation

AUD Alcohol use disorder

CAM Complementary and alternative medicine

CAPS Clinician-administered PTSD scale

CBASP Cognitive Behavioural Analysis System of Psychotherapy

CBT Cognitive behavioural therapy

CBGT Cognitive-based Group Therapy

CPE Cognitive psychological education

DPFC Dorsolateral prefrontal cortex

DVA Department of Veterans' Affairs

FDA United States Food and Drug Administration

GABA Gamma-aminobutyric acid

GAD Generalised anxiety disorder

HEP Health-Enhancement Program

HLW Healthy Living Workshop

HRV Heart rate variability

mADM Maintenance anti-depressant medication

MAGT Mindfulness and Acceptance-based Group Therapy

MBCT Mindfulness-based Cognitive Therapy

MBCT-TS Mindfulness-based Cognitive Therapy support to taper or discontinue antidepressant treatment

MBI Mindfulness-based intervention

MBRP-A Mindfulness-based relapse prevention for alcohol

MBSR Mindfulness-based Stress Reduction

MDD Major depressive disorder

MORE Mindfulness-Oriented Recovery Enhancement


Term Definition

MRP Mantram repetition program

NE Norepinephrine

OB/GYN Obstetrician/gynaecologist

OFC Orbitofrontal cortex

PCL PTSD checklist

PCT Present-centred therapy

PCGT Present-centred group therapy

PCBMT Primary Care Based Mindfulness Training

PFC Prefrontal cortex

PICO Population Intervention Comparison Outcome framework

PNS Parasympathetic nervous system

PTSD Posttraumatic stress disorder

RCT Randomised controlled trial

REA Rapid evidence assessment

SAD Social anxiety disorder

SKY Sudarshan Kriya Yoga

SME Stress management education

SNS Sympathetic nervous system

SRF Self-referential processing

SSRI Selective serotonin reuptake inhibitor

STAI State-Trait Anxiety Inventory

TAU Treatment as usual

TRD Treatment resistant depression

UK United Kingdom

US/USA United States of America

VA US Department of Veterans Affairs

VHA US Veteran Health Administration

WL Waitlist

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8

Executive Summary

The aim of this rapid evidence assessment (REA) was to assess the evidence related to

meditation and mindfulness practices (meditation, transcendental meditation, mantra,

yoga, and mindfulness) for posttraumatic stress disorder (PTSD), depression, anxiety,

and alcohol use disorder (AUD) in adults.

To address this aim, the research team at Phoenix Australia was commissioned by DVA

to answer the following three questions:

1. What role does meditational practice including meditation, transcendental meditation,

mantra, and yoga have in mental health treatment options?

2. What is the efficacy of mindfulness as a mental health treatment option when

compared to conventional treatment?

3. Is there any benefit for mindfulness, meditation, transcendental meditation, mantra,

or yoga to be used as an adjunct with conventional therapy approaches for PTSD,

depression, anxiety, or AUD?

A literature search was conducted to identify trials that investigated the efficacy of

meditation and mindfulness practices for treating PTSD, depression, anxiety, and AUD.

Trials were excluded if the full text was unavailable, if the practice was not investigated

as a treatment, if the paper was not peer reviewed, if the primary outcome measures

were not the focus of the review (i.e., PTSD, depression, anxiety, AUD, stress, wellbeing,

and arousal symptoms), and if they did not concern the population of interest (i.e.,

adults). Given that there was a large amount of literature found for meditation and

mindfulness practices, only randomised controlled trials (RCTs) or systematic reviews

and meta-analyses were examined. Other study designs were excluded. Trials were

initially assessed for quality of methodology, risk of bias, and quantity of evidence.

Subsequently, the consistency, generalisability, and applicability of the findings to the

population of interest was assessed. Assessments were then collated for each

meditation and mindfulness practice type to determine an overall ranking of level of

support for each type of practice for the treatment of PTSD, depression, anxiety, and

AUD.

The ranking categories were: ‘Supported’ – clear, consistent evidence of beneficial effect;

‘Promising’ – evidence suggestive of beneficial effect but further research required;

‘Unknown’ – insufficient evidence of beneficial effect; ‘Not supported’ – clear, consistent

evidence of no effect or negative/harmful effect.


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Forty-eight original trials met the inclusion criteria for review. Additionally, one paper

reported a secondary analysis which was conducted on an original trial, and one paper

reported a longer-term follow-up of an original trial, totalling 50 papers. Approximately

half (26) of the trials originated from the United States. There were three trials from

Canada, two each from Sweden, Iran, India, Germany, the UK, and the Netherlands, and

one each from Columbia, Taiwan, Croatia, Austria, Hong Kong, Vietnam, and Australia,

totalling 48 original trials.

Stand-alone interventions were evaluated in 79% of the total original trials. Stand-alone

interventions comprised 38% yoga, 31% mindfulness-based interventions, and 10%

meditational practices (meditation 2%, transcendental meditation 2%, mantram repetition

meditation 4%, and combined yoga/meditation 2%), totalling 79%.

Adjunct interventions were evaluated in 21% of the total original trials. Adjunct

interventions comprised 13% yoga and 8% mindfulness-based interventions, totalling

21%. There were no meditation-based adjunct interventions.

The most frequently investigated interventions (whether stand-alone or adjunct) were

yoga (50%), followed by mindfulness (40%), mantram repetition meditation (4%),

meditation (2%), transcendental meditation (2%), and a combined yoga/meditation

intervention (2%).

Most of the trials targeted depression (39%), followed by PTSD (25%), anxiety (13%),

depression and anxiety together (13%), and AUD (10%).

Meditation, including mantram meditation and transcendental meditation, was used for

depression (2% of all trials) and PTSD (6%). Yoga was used mostly for depression

(21%), followed by PTSD (13%), depression and anxiety (10%), AUD (4%), and anxiety

(2%). Mindfulness was also used mostly for depression (15%), followed by anxiety

(11%), PTSD (6%), AUD (6%), and depression and anxiety (2%). Combined meditation

and yoga was used for depression rarely (2%).

Overall, the quality of the trials was mixed, with some high and some poor quality trials.

Of the final 23 groups of interventions, three stand-alone interventions were ranked as

‘Promising’ (group yoga for depression, group mindfulness for depression, and group

mindfulness for anxiety). The remaining 20 groups were ranked as ‘Unknown’. A

summary of the 23 groups and their rankings follows.

The key findings for the 11 groups of stand-alone meditational practice interventions

were that:


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o the evidence for group meditation in treating PTSD (compared to a non-

active comparison) (1 trial) received an ‘Unknown’ ranking

o the evidence for group meditation in treating PTSD (compared to an active

comparison) (1 trial) received an ‘Unknown’ ranking

o the evidence for individual meditation in treating PTSD (compared to an


o the evidence for group meditation in treating depression (compared to a

non-active comparison) (1 trial) received an ‘Unknown’ ranking

o the evidence for group yoga in treating PTSD (compared to a non-active

comparison) (5 trials) received an ‘Unknown’ ranking

o the evidence for group yoga in treating depression (compared to a non-

active comparison) (6 trials) received a ‘Promising’ ranking

o the evidence for individual yoga in treating anxiety (compared to a non-


o the evidence for group yoga in treating depression and anxiety together

(compared to a non-active comparison) (4 trials) received an ‘Unknown’

ranking

o the evidence for individual yoga in treating depression and anxiety together

(compared to a non-active comparison) (1 trial) received an ‘Unknown’

ranking

o the evidence for group yoga (hatha yoga) in treating AUD (compared to a

non-active comparison) (1 trial) received an ‘Unknown’ ranking

o the evidence for group yoga/meditation in treating depression (compared to

a non-active comparison) (1 trial) received an ‘Unknown’ ranking.

The key findings for the six groups of stand-alone mindfulness-based interventions

compared to an active comparison group were that:

o the evidence for group mindfulness in treating PTSD (compared to an active

comparison) (2 trials) received an ‘Unknown’ ranking

o the evidence for group mindfulness in treating depression (compared to an



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o the evidence for individual mindfulness treating depression (compared to an


o the evidence for group mindfulness in treating anxiety (compared to an


o the evidence for group mindfulness in treating depression and anxiety

together (compared to an active comparison) (1 trial) received an ‘Unknown’

ranking

o the evidence for group mindfulness in treating AUD (compared to an active

comparison) (3 trials) received an ‘Unknown’ ranking.

The key findings for the six groups of adjunct meditation, yoga, and mindfulness-based

interventions were that:

o the evidence for group adjunct yoga (adjunct to psychopharmacological

treatment) in treating PTSD (compared to an active comparison) (1 trial)

received an ‘Unknown’ ranking

o the evidence for group adjunct yoga (adjunct to pharmacological treatment)

in treating depression (compared to an active comparison) (3 trials) received

an ‘Unknown’ ranking

o the evidence for group adjunct yoga (adjunct to psychoeducation) in treating

depression (compared to a non-active comparison) (1 trial) received an

‘Unknown’ ranking

o the evidence for group adjunct yoga (adjunct to psychological and

pharmacological treatment) in treating AUD (compared to an active

comparison)(1 trial) received an ‘Unknown’ ranking

o the evidence for group adjunct mindfulness (adjunct to pharmacological

treatment) in treating PTSD (compared to an active comparison) (1 trial)

received an ‘Unknown’ ranking

o the evidence for group adjunct mindfulness in treating depression

(compared to an active comparison) (3 trials) received an ‘Unknown’ ranking.

Despite the predominantly ‘Unknown’ rankings, the findings of this review do provide

some guidance on where future research efforts should be directed. The three

‘Promising’ interventions (group yoga for depression, group mindfulness for depression,

and group mindfulness for anxiety) require further rigorous trials to attain a ‘Supported’


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ranking. At this time they may be considered emerging interventions, but not first-line

treatments.

The conclusion drawn from the available evidence is that the research is not of

sufficiently high quality to support any direct recommendations. Even though there is

some research of sufficient quality to suggest yoga and mindfulness being useful in the

treatment of depression and anxiety, there is an opportunity to focus on funding well

designed, high quality research in this area to build an evidence base that would inform

the use of these modalities in treatment for mental health conditions, especially as it

relates to understanding the underlying mechanisms of these approaches. In the short

term, further research in the areas that have a promising ranking, that is, yoga and

mindfulness for treating depression and anxiety may be beneficial.


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Introduction

This review examined meditation, including mantram meditation and transcendental meditation,

yoga, and mindfulness. The common link between these practices is the mind-body

connection,1,2 or the interaction between the brain, mind, body, and behaviour.3 These practices

were examined in light of their psychotherapeutic applications to posttraumatic stress disorder

(PTSD), depression, anxiety, and alcohol use disorder (AUD), rather than their Eastern

philosophical origins.

There is much overlap between the practices in the techniques, skills, and objectives of each,

and in the mechanisms of action exerted on PTSD, depression, anxiety and AUD

symptomatology. Where possible, the unique aspects of each practice have been identified, but

in many cases, reference is made to the more general ‘meditation, yoga, and mindfulness

practices’.

Meditation, mantram meditation, and transcendental

meditation

The term ‘meditation’ encompasses a variety of practices, ranging from relaxation techniques to

exercises performed with the goal of attaining a heightened sense of wellbeing.4 There are three

broad types of meditation which are differentiated based on the particular focus of attention, and

the level of individual effort exerted by the practitioner.5 The first type, concentrative (focussed

attention) meditation involves voluntary and sustained attention on a chosen object, such as

breath or a word or phrase (e.g., a mantram). The second type, mindful (open monitoring)

meditation involves non-reactive monitoring of the moment-to-moment content of experience, for

example, mindfulness meditation. And the third type, automatic self-transcending meditation

(ASTM), requires the absence of both focus and individual control or effort. Mind-body practices

such as yoga and tai chi have a meditation component.6

Yoga

Originating as a discipline to help relieve suffering and disease, today yoga is used by many

people in the West as an holistic wellness approach.7 In Australia, yoga is practised as a form of

exercise (improved health, fitness, flexibility, and muscle tone), as a spiritual practice, a form of

personal development, to reduce stress or anxiety, and for specific health or medical reasons.8

There are many types of yoga which can be distinguished by the emphasis placed on particular

features such as spirituality, breathing, intensity of physical postures, and relaxation. Some of the

more prominent types of yoga are described here.


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Hatha yoga is the foundation for all yoga styles, and refers to any practice that combines asana

(physical postures), pranayama (breathing techniques), and meditation.9 Postures are done

mindfully and with awareness of breathing, reinforcing the overlap between yoga and

mindfulness. Kundalini yoga is highly spiritual, involving more chanting, meditation, and mantras

than other types of yoga, and promotes deep relaxation.10 Other yoga types include Sudarshan

kriya yoga, involving controlled breathing and meditation,11 and Vinyasa yoga, which involves

movement through a sequence (or ‘flow’) of poses.12 Yoga nidra focusses on relaxation and is

also known as yoga relaxation therapy.13 Therapeutically, yoga is usually delivered in group

format, although it can be taught individually, and may be tailored to the patient’s needs. Patients

are also encouraged to practise yoga skills outside of therapy sessions.7

Mindfulness

Mindfulness involves intentionally bringing one’s attention to the internal and external

experiences occurring in the present moment.14 Although mindfulness is said have been inspired

by 2500-year-old Buddhist meditation practice,15 in contemporary Western psychology research

and clinical contexts, it is usually taught independently of the cultural, religious, and ideological

factors associated with its Buddhist origins.14

An operational working definition of mindfulness presents it as a two-component construct

comprising, (1) self-regulation of attention to the present moment, coupled with (2) an attitude of

acceptance towards the present moment.16 Mindfulness may be described as a state, a trait-like

or dispositional quality, or a set of skills.17 Two key features of the definition of mindfulness are

awareness and acceptance, both of which are accompanied by a nonjudgmental attitude.18

Awareness refers to the perception of current experiences, including bodily sensations,

cognitions, emotions, urges, and environmental stimuli such as sights, sounds, and scents.17

Acceptance refers to the openness (curiosity, detachment, irregular thinking) to face personal

experiences.19 Mindfulness practice, therefore, encourages practitioners to remain in the present

moment, whether pleasant, unpleasant, or neutral.17 Awareness and acceptance are

underpinned by the self-regulation of attention, and orientation toward the present moment.20

Therapeutic application of mindfulness

Therapeutic applications of mindfulness are commonly called mindfulness-based interventions

(MBIs).15 The first MBI, Mindfulness-Based Stress Reduction (MBSR), was developed in 1979 by

Professor Jon Kabat-Zinn from the University of Massachusetts Medical Centre. The original

intent of MBSR was to help outpatients attending a stress reduction clinic to relieve the suffering

associated with stress, pain, and illness.15 Since then, other programs based on the foundational

and structural approach of MBSR have been developed.21 These include Mindfulness-Based

Cognitive Therapy (MBCT),22 which was developed to treat recurrent depression, and two


15

addiction recovery MBIs, Mindfulness-Oriented Recovery Enhancement (MORE)23 and

Mindfulness-Based Relapse Prevention (MBRP).24 Mindfulness components are also

incorporated in Dialectical Behaviour Therapy (DBT) and Acceptance and Commitment Therapy

(ACT).25

There are a number of mindfulness techniques taught in MBIs including: mindful breathing,

mindful eating, body scan meditation, sitting meditation, mindful yoga, and walking meditation.17

Hatha yoga is a component of MBSR,26 and practising mindfulness is a key element to most

styles of Hatha yoga.9 All of these techniques involve paying close attention to the physical

sensations and actions that are involved in otherwise automatic actions or processes. For

example, during mindful breathing, individuals focus all their attention on the physical sensations

associated with breathing.27 The goal of all of these interventions is to observe and accept

physical sensations in a nonjudgmental manner without trying to alter them. Appendix 6 contains

a brief overview of the mindfulness practices and curriculum used in the MBIs included in this

review.


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Impactful components of meditation, yoga, and

mindfulness

Through the use of meditation, yoga, and mindfulness techniques, practitioners acquire skills and

abilities which might be thought of as the impactful components, or ‘active ingredients’ that

underpin a range of beneficial psychological, behavioural, and neurophysiological changes.

Some of the impactful components that may contribute therapeutically to the treatment of PTSD,

depression, anxiety, and AUD are described briefly below.

Acceptance is a central feature of mindfulness that refers to a willingness to experience

the array of one’s thoughts and emotions without judgement.16,28 It aims to reduce the

distress that is associated with trying to change one’s thoughts or emotional states, for

example, preventing individuals from feeling anxious about being anxious.29

Describing refers to the practice of labelling sensations, perceptions, thoughts, and

emotions with words, for example, ‘I feel happy’ or ‘my heart is racing’.30 The benefit of

describing is that it allows individuals to be more keenly aware of thoughts, sensations and

emotions and better able to talk about them in treatment.28

Present-centred awareness refers to focussing on what is happening in the present

moment.31 By limiting the scope of attention to what is happening in the moment, habitual

judgmental tendencies are de-automatised, meaning that instead of evaluating

experiences in terms of past memories and future expectations, practitioners merely note

what is taking place in the moment, and observe their experience and reactions.28

Breathing techniques such as slowed breathing which often occur during meditation,

yoga, and mindfulness practices have the effect of increasing activation of the

parasympathetic nervous system (PNS), which helps to reduce stress.32

Physical postures practised during yoga may yield the exercise-induced

psychotherapeutic benefits conferred by most forms of physical activity,33 in addition to

fostering increased body awareness, including tension, and a sense of confidence and

control over the body.34


17

Mechanisms underpinning meditation, yoga, and

mindfulness-based interventions

A range of neurophysiological, psychological, and behavioural mechanisms have been proposed

to explain why meditation, yoga, and mindfulness-based interventions may be able to reduce

PTSD, depression, anxiety, and AUD symptomatology.

Neurophysiological mechanisms

Underpinning the psychological and behavioural changes associated with meditation, yoga, and

mindfulness are three broad neurophysiological responses: alterations to brain function and

structure,35 neurochemical responses,36 and re-balancing of the autonomic nervous system

(ANS).37

Alterations to brain function and structure. Brain alterations that have been reported in

response to meditation, yoga, and mindfulness include both immediate and reversible

changes in brain activity38 and structure.39 While there is evidence for meditation and

mindfulness-related neuroplasticity (the capacity for creating new neural connections and

growing neurons in response to experience),40 these adaptations may reverse once the

practice of the techniques ceases.41 Taken together, these findings suggest that neural

changes may occur in both brief (e.g., one session) and longer term (e.g., eight weeks)

meditation, yoga, and mindfulness interventions.41

Altered neurochemistry. Changes to brain function and structure are reflected in a range

of neurochemical changes, in particular to neurotransmitters36 and the main stress

hormone cortisol.42 Neurotransmitters (brain chemicals that transmit messages between

cells) can become dysregulated in individuals with psychological disorders, for example

PTSD,43 depression,44 and AUD.45 Practising meditation, yoga, and mindfulness is

associated with normalisation of gamma-Aminobutyric acid (GABA), a neurotransmitter

involved in inhibition of nervous system activity,42 and serotonin, dopamine, and

norepinephrine (NE)/noradrenaline, which are neurotransmitters that are related to limbic

system activity, emotional function and control, behaviour regulation, physiological arousal,

mood, reward and motivation, sleep, and other functions.36 The normalisation of

neurotransmitters associated with meditation, yoga, and mindfulness may therefore lead to

stabilisation of functions such as mood and sleep.46,47

Re-balancing of the autonomic nervous system (ANS). The ANS regulates bodily

functions such as heart rate, digestion, and respiratory rate, and operates largely

unconsciously.48 Its two divisions, the sympathetic nervous system (SNS) and the

parasympathetic nervous system (PNS), act together as the body’s major stress response


18

system. During times of stress the SNS is activated, while during times of relaxation the

PNS is activated.48 Individuals with psychological disorders are often characterised by

dominant SNS activity.42

Yoga has been associated with increased PNS activity and reduced overactivity of the

SNS, thereby re-balancing the stress response system.42 Beneficial changes in autonomic

markers such as cortisol, blood pressure, resting heart rate, heart rate variability (HRV),

fasting blood glucose, and cholesterol have been observed in meditation and yoga

practitioners, suggesting that the practice may contribute to increased PNS

activation.37,49,50 Additional correction of PNS underactivity may occur via stimulation of the

vagus nerve (two nerves that begin at the brain stem and pass through the neck, head,

chest, and abdomen), the main peripheral pathway of the PNS.42 Vagus nerve stimulation

is a US Food and Drug Administration (FDA) approved treatment for depression.51

Psychological and behavioural mechanisms

Psychological and behavioural mechanisms of meditation, yoga, and mindfulness include

improvements in self-regulation, attention regulation, and emotion regulation, reductions in

negative self-referential processing, repetitive thinking, rumination, and worry, increased self-

compassion, and increased sensory and body awareness.

Self-regulation refers to the processes by which people manage their own goal-directed

behaviour.52 Behavioural self-regulation failure contributes to addictive behaviours,52

depression and anxiety,53 and PTSD.54 Mindfulness meditation is believed to enhance self-

regulation through the interaction of its core components: attention control, emotion

regulation, and self-awareness.55

Attention regulation is cultivated by meditation, yoga, and mindfulness techniques

through focussing attention on a chosen object, and deliberately returning attention to the

object whenever distracted.4 These techniques aim to enhance the self-regulated ability to

both sustain and switch attention.16 Enhanced attentional regulation through meditation,

yoga, and mindfulness is underpinned by evidence of increased activity in areas including

the anterior cingulate cortex (ACC) and the dorsolateral prefrontal cortex (DPFC), which

are neural structures involved in attentional control.55

Emotion regulation refers to strategies that can influence which emotions arise and

when, how long they occur, and how these emotions are experienced or expressed.55

Effective emotion regulation strategies include reappraisal and support seeking, while less

effective strategies include rumination, worry, and substance use.56 There is abundant

evidence linking emotion regulation difficulties with psychopathology, including depression

and anxiety (E.g., 57), anxiety and PTSD (E.g., 58), and alcohol use disorder (AUD, E.g., 59).


19

Proposed mindfulness-based emotion regulation strategies include paying more attention

to emotions, and changing the way one thinks about uncomfortable or unwanted

emotions.55

The neurophysiological underpinnings of enhanced emotional regulation relate to

alterations in the emotion processing areas of the brain including the orbitofrontal cortex

(OFC), ACC, amygdala, insula, prefrontal cortex (PFC), and hippocampus.60 Importantly, it

is the connectivity between the amygdala and the PFC that governs the ability to regulate

emotions. The PFC acts to inhibit activity in the amygdala.61 If the PFC is underactive, the

amygdala becomes overactive.35 Individuals with disorders such as PTSD and anxiety are

characterised by an overactive amygdala and an underactive PFC.43 Meditation and

mindfulness practices have been associated with changes in activation of these brain

regions, including increased activation of PFC, reduced activation of the amygdala, and

increased functional connectivity between the PFC and amygdala.60 The hippocampus,

PFC, and amygdala are also implicated in fear extinction and safety signalling (or learned

safety).62

Reduced negative self-referential processing. Self-referential processing (SRP) refers

to responses made to stimuli that are intrinsically related to one’s own person,63 and can

be a healthy form of self-reflection and self-regulation.64 However, negative SRP (e.g.,

rumination, worry, self-criticism) frequently accompanies mental health problems.64

Mindfulness meditation may mitigate negative SRP by a process called ‘decentring’ which

is the process of seeing thoughts or feelings as objective events in the mind rather than

personally identifying with them.65 This has the effect of distancing oneself from negative

thoughts.22 Decentring allows an individual to become more aware of their thoughts and to

observe them in a more decentred and objective way, as opposed to unconsciously

identifying with them, perhaps thereby generally reducing negative SRP.66

Mid-cortical brain regions associated with meditative and mindfulness practices are also

implicated in self-referential processing.63

Reduced repetitive thinking, including rumination and worry. Repetitive patterns of

thought that are non-productive can be characterised as rumination, whereby individuals

tend to perseverate over events that have occurred in the past (characteristic of

depression), or worry about events that may occur in the future (the central defining

feature of anxiety).64 This type of thinking is thought to decrease through paying greater

attention to the present moment, as paying attention to the present reduces the time spent

ruminating about the past or worrying about the future.67 Mindfulness meditation and yoga,

through their cultivation of present-centred awareness, have been associated with a

decrease in ruminative thought patterns.9,68


20

The process of decentring, the benefits of which were explained concerning negative SRP,

is also thought to mitigate ruminative thought processes.68 By detaching from their

thoughts, individuals may relate to them more mindfully, rather than reactively and

ruminatively.68

Increased self-compassion. Self-compassion entails “being kind and understanding

toward oneself in instances of pain or failure rather than being harshly self-critical,

perceiving one’s experiences as part of the larger human experience rather than seeing

them as isolating, and holding painful thoughts and feelings in mindful awareness rather

than over-identifying with them” (p.139).69 Self-compassion is cultivated through loving-

kindness meditation,70 yoga,71 and mindfulness practices.69 There is evidence that self-

compassion stimulates parts of the brain associated with compassion in general.72,73

Increased sensory and body awareness. Body awareness is the ability to notice subtle

bodily sensations, and involves focussing on sensory experiences such as breathing, or

emotions.74 These abilities are beneficial for individuals with disorders which require the

modulation of physiological arousal, such as anxiety and PTSD.32 Increased body and

sensory awareness (interoceptive awareness) via mindfulness training has been

associated with structural and functional changes in the brain.75


21

Meditation, yoga, and mindfulness for PTSD

Meditation, yoga, and mindfulness approaches may target core symptoms of PTSD, including

avoidance, hyperarousal, emotional numbing, negative emotions, and dissociation.35

Contributing to these therapeutic benefits may be neurophysiological changes related to emotion

and stress reactivity, and at least four psychological constructs: attention regulation, present-

centred awareness, nonjudgment, and self-compassion.76 The potential neurophysiological and

psychological mechanisms are discussed in detail below.

Neurophysiological mechanisms by which mindfulness, yoga, and meditation techniques may

reduce PTSD symptoms include the restoration of the neurocircuitry involved in emotion

regulation and fear extinction (e.g., increased amygdala-PFC connectivity),77 structural changes

to the brain that improve body and emotion awareness,75 and tempered physiological arousal

and stress reactivity.35

Psychological mechanisms include at least four psychological constructs. First, attention

regulation may lead to reductions in attentional bias to trauma-related stimuli, which is

characteristic of individuals with PTSD. Shifting attention away from trauma-related stimuli and

remaining in the present moment is thought to improve intrusive and hyperarousal symptoms.35

Second, paying attention to the present moment redirects past or future-directed thoughts and

may therefore reduce repetitive thinking, such as rumination and worry.76 Third, nonjudgmental

acceptance may promote a willingness to approach fear-provoking stimuli, leading to reduced

avoidance,76 in addition to potentially reducing the symptoms of emotional numbing and

suppression of intrusive thoughts.78 It has been proposed that via the combined mindfulness

skills of nonjudgmental acceptance and present-centred awareness, mindfulness meditation

resembles exposure therapy.28 In other words, sustained nonjudgmental observation and

acceptance of difficult emotions, without attempts to escape or avoid them,28 may lead to

reductions in the emotional reactivity typically elicited by anxiety symptoms, and increased fear

tolerance.14 And fourth, self-compassion may promote the ability to experience positive feelings

toward the self, thereby reducing the negative emotions of shame, guilt, and anger.35

A cautious approach is recommended when considering the therapeutic use of mindfulness to

treat PTSD. People who are particularly prone to flashbacks or easily triggered trauma memories

may experience additional distress given that mindfulness-based approaches increase exposure

to traumatic memories by reducing avoidance. Furthermore, people who have not developed

distress tolerance skills may initially have difficulty coping with unwanted intrusive images.35


22

Meditation, yoga, and mindfulness for depression

In the treatment of depression, neurophysiological mechanisms attributed to mediation, yoga,

and mindfulness include neurotransmitter and hormone normalisation, and alterations to brain

regions that are implicated in depression. Furthermore, commonly cited psychological and

behavioural mechanisms include improved emotion regulation, reduced rumination, and negative

self-referential processing (SRP), increased behavioural activation, and improved sleep

regulation. The potential neurophysiological, psychological, and behavioural mechanisms are

discussed in detail below.

Neurophysiologically, meditation and yoga have been reported to normalise serotonin levels36

which are lowered in depressed individuals.79 Additionally, yoga postures may be linked to

exercise-induced increases in hippocampal volume,80 mitigating the hippocampal atrophy seen in

depressed patients.44 Further exercise related benefits of yoga include a reduction in the stress

hormone, cortisol, via normalisation of the hypothalamic-pituitary-adrenal (HPA) axis.81

In terms of psychological and behavioural mechanisms, improved emotion regulation, reduced

rumination and negative self-focus, and improved behavioural activation are thought to decrease

depressive symptomatology. Improved emotional regulation is associated with mindfulness via

the increased use of an emotion regulation strategy known as reappraisal.74 Reappraisal

involves reframing a situation’s meaning to alter one’s emotional response to the situation.82

Taking a nonjudgmental stance toward experience, which is in itself a form of reframing67, is

thought to underpin the increase in positive appraisal associated with mindfulness.83 Thus,

mindfulness may cultivate a more general tendency toward reappraisal of initial negative

cognitions.84

Mindfulness and meditation are linked with reductions in rumination and negative SRP,66,85 both

of which are characteristic of depressed individuals.86 Depression involves an increased negative

self-focus, which is persistent, repetitive, and self-critical in nature.87 Mindfulness practice,

through nonjudgment, reduces the automatic engagement in, and reaction to, evaluative mental

states,88 thereby mitigating negative self-evaluative thoughts.67

Behavioural activation, an important treatment option for depression,89 is promoted by both the

physical activity component of yoga, and the attitude of curiosity about experiences and

acceptance of distressing thoughts and emotions cultivated through mindfulness training.9 Yoga

may also improve sleep irregularities which are commonly experienced by individuals

experiencing depression.9


23

Meditation, yoga, and mindfulness for anxiety symptoms

Many of the neurophysiological and psychological mechanisms presented in the section on

PTSD treatment also apply to the treatment of anxiety symptoms due to several similarities.

These similarities include attentional bias toward threat, worry, emotional dysregulation, and

physiological reactivity.90 Potential neurophysiological mechanisms include reduced activity in

fear-related brain regions and normalisation of neurotransmitters, and psychological mechanisms

may include attention regulation, reduced worry, and enhanced emotion regulation. These

potential mechanisms are discussed in detail below.

The neurophysiological mechanisms in relation to anxiety symptoms closely resemble those

related to PTSD, including alterations in brain regions involved in the regulation of emotion, for

example, reduced amygdala activation77 and normalisation of neurotransmitters, including

GABA, serotonin, and NE.36

The self-regulation of attention, a central facet of meditation and mindfulness,4 is an important

therapeutic application of mindfulness for anxiety symptoms because it addresses the tendency

in anxious individuals to direct attention toward hypervigilant scanning for cues of threat or

danger.91 Increasing control over the allocation of attention is therefore one conceivable way that

MBIs reduce symptoms of anxiety.91

Contributing to hypervigilance is worry, which is a future-oriented form of repetitive thinking.64

High levels of worry interfere with problem solving, emotional processing, and present moment

focus.92 Similarly to reductions in rumination (another type of repetitive thinking), MBIs also

appear to reduce worry via the dual facets of nonjudgment and present-centred focus.67

Emotion regulation difficulties are thought to underpin the motivation to avoid distressing internal

experiences, which is characteristic of individuals with anxiety symptoms.93 The cultivation of

awareness, acceptance, and nonjudgment via meditation, yoga, and mindfulness practices

targets the avoidant responses to internal experiences by supporting the willingness to remain

present in a nonjudgmental way rather than trying to control symptoms.93


24

Meditation, yoga, and mindfulness for alcohol use disorder

(AUD)

Meditation, yoga, and mindfulness-based interventions are thought to improve AUD

symptomatology through neurophysiological alterations in the mesolimbic dopamine system,

which is involved in motivation and reward, and by increasing PNS activity, which has the effect

of lowering physiological stress. Psychological and behavioural mechanisms may include

improved craving management, reduced compulsive and impulsive behaviour, enhanced

emotion regulation, and decreased experiential avoidance. The potential neurophysiological,

psychological, and behavioural mechanisms are discussed in detail below.

The mesolimbic dopamine system plays an important role in the reinforcement of drinking

behaviour.94 AUD is associated with low dopamine levels which provides the continued

motivation to drink alcohol,95 therefore by inducing dopamine homeostasis, meditation and yoga

may be beneficial for treating AUD.96,97 Stress reduction is also therapeutic for AUD, particularly

during withdrawal. Discontinuation of alcohol is associated with increased SNS activity98 which

can be mitigated by PNS activity induced by techniques such as yogic breathing.99

Mindfulness promotes the awareness of triggers for craving alcohol, and cultivates the ability to

choose to do something else which might ameliorate or prevent craving.100 Through

nonjudgmental awareness, the habitual cue-response pattern is disrupted and the craving

response accepted without analysing, or reacting.101 In this way, meditation acts as a form of

counter-conditioning, contributing to the reversal of learned responses which are implicated in

addiction.101 Mindfulness may therefore reduce both compulsive behaviour, by providing a

coping strategy to deal with urges and temptations (learning to accept and tolerate urges,

choosing to do something else), and impulsive behaviour, by reducing susceptibility to act in

response to a cue stimulus.101

Alcohol misuse may be developed and sustained through dysregulated emotion and/or

experiential avoidance, both of which may be mitigated by meditation, yoga, and

mindfulness.102,103 Individuals with AUD frequently display deficits in emotion regulation, using

alcohol to regulate their current emotional state (e.g., to reduce negative emotion or increase

positive emotion), or to regulate the experience of craving.103 As previously described,

mindfulness may enhance emotion regulation and therefore reduce reliance on alcohol to

regulate emotional states.55 The desire to avoid unpleasant life circumstances (avoidance) may

also occur in the case of addiction.104 Acceptance might be thought of as ‘experiential presence’

(the opposite of experiential avoidance), therefore, in a similar application to PTSD treatment,

avoidance may be reduced through the mindfulness skill of acceptance.102


Method

25

This literature review utilised a rapid evidence assessment (REA) methodology. The REA is a

research methodology that uses similar methods and principles to a systematic review, but

makes concessions to the breadth and depth of the process in order to suit a shorter timeframe.

The advantage of an REA is that it utilises rigorous methods for locating, appraising, and

synthesising the evidence related to a specific topic of enquiry. To make an evidence

assessment rapid, however, the methodology places a number of limitations on the search

criteria and on how the evidence is assessed. For example, REAs often limit the selection of

studies to a specific time frame (e.g., last 10 years), and limit selection of studies to peer-

reviewed published, English studies (therefore not including unpublished pilot studies, difficult-to-

obtain material, and/or non-English language studies). Furthermore, while the strength of the

evidence is assessed in a rigorous and defensible way, it is not necessarily as exhaustive as a

well-constructed systematic review and meta-analysis. A major strength however, is that an REA

can inform policy and decision makers more efficiently by synthesising and ranking the evidence

in a particular area within a relatively short space of time and at less cost than a systematic

review/meta-analysis.

Defining the research question

The components of the question were precisely defined in terms of the population, the

interventions, the comparisons, and the outcomes (PICO – refer to Appendix 1). Operational

definitions were established for key concepts for each question, and from this, specific inclusion

and exclusion criteria were defined for screening trials for this REA. As part of this operational

definition, the population of interest was defined as healthy adult patients (i.e., not suffering from

a life-threatening disease) with PTSD, depression, anxiety, or AUD (or subclinical features of one

or more of these disorders); the intervention was defined as the administration of meditation,

yoga, or mindfulness for the treatment of PTSD, depression, anxiety, or AUD; and the mental

health outcomes were defined as improvements in symptoms of PTSD, depression, anxiety,

AUD, stress, arousal, and improvements in wellbeing.

Question 1 in this review investigated the use of stand-alone meditation and yoga interventions

to treat PTSD, depression, anxiety, and AUD. When conducting the literature search for this

question, interventions compared to any comparison condition were included. These comparison

conditions included pharmacotherapy, therapy, assessment only, and waitlist. However, in

presenting the findings and ranking the evidence, trials comparing meditation and yoga

interventions to active comparison conditions (i.e. conventional psychological or pharmacological

treatments) were separated from those comparing to non-active comparison conditions (e.g.

assessment only or waitlist). In order to be considered a beneficial intervention, the meditation or


26

yoga treatment had to yield greater benefits in symptom reduction than the non-active control

conditions in superiority trials, or demonstrate non-inferiority to active comparison conditions in

non-inferiority trials.

Question 2 examined the use of stand-alone mindfulness interventions for the treatment of

PTSD, depression, anxiety, and AUD. For this research question, the comparison groups were

limited to those providing conventional psychological or pharmacological treatments for the

specified disorders. As such, in order to be considered beneficial, the mindfulness interventions

had to demonstrate non-inferiority to conventional treatments.

Question 3 consisted of an investigation of meditation (including yoga) and mindfulness

interventions as adjunct to conventional treatment for PTSD, depression, anxiety, and AUD. As

with Question 1, the literature search included comparisons to active and non-active comparison

conditions, but trials with active comparison were separated from those with non-active

comparison conditions when it came to ranking the evidence and presenting the findings. In

order to be considered a beneficial intervention, adjunct meditation and mindfulness treatments

had to display greater benefits than the conventional treatment alone.

Search strategy

To identify the relevant literature, systematic bibliographic searches were performed to find

relevant trials from the following databases: PsycInfo, EMBASE, PubMed, CINAHL, Health

Collection, and the Cochrane Database of Systematic Reviews.

Search terms

Search terms specific to the meditation, yoga, and mindfulness practices, and psychiatric

disorders of interest, were included. Searches were conducted between 22 and 28 June 2018

according to the following search terms and limits.

Interventions

Mindfulness: mindfulness, mindfulness therapy, mindfulness-based stress reduction,

MBSR

Meditation and transcendental meditation: meditation, transcendental meditation,

meditative therapy, meditative psychotherapy, meditation therapy, meditation

psychotherapy

Mantra: mantra, mantra* meditation

Yoga: yoga, yoga therapy, yoga treatment, yogic


27

Specific meditation/mantra/yoga terminology: vipassana, zen, pranayama, sudarshan,

kriya, qi-gong, qigong, chi kung, kundalini, chundosunbup, reiki, tai chi, relaxation

therapy, asana, dhyana, dharana.

Psychiatric disorders

Depression: depression, major depression, major depressive disorder, MDD

Anxiety: anxiety, anxiety disorder, generali*ed anxiety, GAD

PTSD: post-traumatic stress disorder, posttraumatic stress disorder, PTSD, post-

traumatic stress, posttraumatic stress, traumatic stress

Alcohol: alcohol, alcohol use disorder, AUD, alcohol use, alcohol abuse.

Databases: search fields

PsycInfo: Title, abstract, key concepts

Embase: Title, abstract, keyword

PubMed: Title/abstract

CINAHL: Title, abstract

Health Collection: Title, abstract

Cochrane: Title.

Limits placed on searches

All searches were limited to English language

All searches were limited to the period 2010 to current

For mindfulness only, search results were limited to RCTs by using the following

additional search terms: "RCT" "randomised controlled trial" "clinical trial" "random"

"random allocation" "control trial" "randomized controlled trial" "systematic review" "meta-

analysis" "effectiveness trial".

An example of the search strategy conducted in the Embase database appears in

Appendix 2.


28

Paper selection: Question 1 Stand-alone meditation and

yoga treatments

Papers were included in the review of the meditational practices evidence if they met all of the

following inclusion criteria.

Included:

1. Internationally and locally published peer-reviewed research trials.

2. Research papers that were published from 2010 to current.

3. Human adults (i.e., ≥ 18 years of age).

4. English language.

5. Sample consisting of individuals with PTSD, depression, anxiety, or AUD (clinical

diagnosis or sub-clinical symptoms).

6. Trials that used meditational practices (i.e., meditation, Transcendental Meditation,

mantram or yoga) to target the symptoms of PTSD, depression, anxiety, or AUD.

7. Trials with outcome data that assessed changes in one or more of the following

domains:

a. PTSD

b. Depression

c. Anxiety

d. AUD

e. Stress

f. Wellbeing

g. Arousal symptoms

8. Only randomised controlled trials (RCTs) were included.

9. Trials with active (e.g. present-centred therapy, prolonged exposure therapy) or non-

active (e.g. treatment-as-usual, waitlist, assessment-only, standard care, attention-

control) comparison conditions were included.

Excluded:

1. Non-English language.

2. Papers where a full text version was not readily available.

3. Children (mean age of sample ≤ 17 years of age).

4. Validation studies.

5. Animal studies.

6. Grey literature (e.g., media: websites, newspapers, magazines, television; conference

abstracts; theses).

7. No quantitative outcome data reported.

8. Intervention targeting phobias or panic disorder.


29

Paper selection: Question 2 Stand-alone mindfulness

treatments

Papers were included in the review of the mindfulness evidence if they met all of the following

inclusion criteria.

Included:






diagnosis or sub-clinical symptoms)

6. Trials that used the mindfulness practice to target the symptoms of PTSD, depression,

anxiety, or AUD.


domains:

a. PTSD

b. Depression

c. Anxiety

d. AUD

e. Stress

f. Wellbeing

g. Arousal


9. Only trials with active comparison conditions were included (e.g. present-centred group

therapy, primary care treatment, cognitive behavioural analysis system of psychological

education, CBT, stress management education, cognitive behavioural group therapy,

psychoeducation, pharmacological treatment, support groups).

Excluded:





5. Animal studies.


abstracts; theses).


8. Intervention only included mindfulness as a small component. For example, Acceptance

and Commitment Therapy, Dialectical Behaviour Therapy.


30

Paper selection: Question 3 Adjunct meditation, yoga, and

mindfulness treatments

Papers were included in the review of the meditation and mindfulness as adjunct evidence if they

met all of the following inclusion criteria.

Included:






diagnosis or sub-clinical symptoms).

6. Trials that used the meditation or mindfulness practice as an adjunct to conventional

psychological or pharmacological treatment to target the symptoms of PTSD,

depression, anxiety, or AUD.


domains:

a. PTSD

b. Depression

c. Anxiety

d. AUD

e. Stress

f. Wellbeing

g. Arousal


9. Trials with active (e.g. psychopharmacologic treatment, pharmacological treatment,

counselling) or non-active comparisons (e.g. treatment-as-usual) were included.

Excluded:





5. Animal studies.


abstracts; theses).



31

Information management

A screening process was adopted to code the eligibility of papers acquired through the search

strategy. Papers were directly imported into the bibliographic tool Endnote X7. Screening for

duplicates was performed in Endnote. References were then imported into Covidence for

screening and for full text review.

All records that were identified using the search strategy were screened for relevance against the

inclusion criteria. Initial screening for inclusion was performed by two reviewers using Covidence,

and was based on the information contained in the title and abstract. Full text versions of all trials

which satisfied this initial screening were obtained.

If the paper met the inclusion criteria it was subject to data abstraction. This involved extracting

the following information: (i) trial description, (ii) intervention description, (iii) participant

characteristics, (iv) primary outcome domain, (v) main findings, (vi) bias, and (vii) quality

assessment. This information appears in the evidence tables in Appendix 4.

Evaluation of the evidence

There were five key components that contributed to the overall evaluation of the evidence.105

1. The strength of the evidence base, in terms of the quality and risk of bias, quantity of

evidence, and level of evidence (study design).

2. The direction of the trial results in terms of positive, negative, or null findings.

3. The consistency of the trial results.

4. The generalisability of the body of evidence to the target population (i.e., adults/military

personnel).

5. The applicability of the body of the evidence to the Australian context.

The first three components provided a gauge of the internal validity of the trial data in support of

efficacy for an intervention. The last two components considered the external factors that may

influence effectiveness, in terms of the generalisability of trial results to the intended target

population, and applicability to the Australian context.

Strength of the evidence base

The strength of the evidence base was assessed in terms of: a) quality and risk of bias,

b) quantity of evidence, and c) level of evidence.


32

a) Quality and risk of bias reflects how well the trial was conducted, including how the

participants were selected, allocated to groups, and managed and followed-up, and how the

trial outcomes were defined, measured, analysed, and reported. An assessment was

conducted for each trial with regard to the quality and risk of bias criteria utilising a modified

version of the Chalmers Checklist for appraising the quality of studies of interventions (see

Appendix 3). Three independent raters rated each trial according to these criteria, and

together reached a consensus agreement on an overall rating of ‘Good’, ‘Fair’, or ‘Poor’.

b) Quantity of evidence reflected the number of trials that were included in the evidence base

for each ranking. The quantity assessment also took into account the number of participants

in relation to the frequency of the outcomes measures (i.e., the statistical power of the trials).

Small, underpowered trials that were otherwise sound may have been included in the

evidence base if their findings were generally similar – but at least some of the trials cited as

evidence must have been large enough to detect the size and direction of any effect.

c) Level of evidence reflected the trial design. Details of the trial designs included in this REA

were assessed against a hierarchy of evidence commonly used in Australia:106

a. Level I: A systematic review of RCTs

b. Level II: An RCT

c. Level III-1: A pseudo-RCT (i.e., a trial where a pseudo-random method of allocation

is utilised, such as alternate allocation)

d. Level III-2: A comparative trial with concurrent controls. This can be any one of the

following:

i. Non-randomised experimental trial (this includes controlled before-and-after

(pre-test/post-test) trials, as well as adjusted indirect comparisons (i.e., utilise

A vs B and B vs C to determine A vs C with statistical adjustment for B))

ii. Cohort study

iii. Case-control study

iv. Interrupted time series with a control group

e. Level III-3: A comparative study without concurrent controls. This can be any one of

the following:

i. Historical control study

ii. Two or more single arm study (case series from two studies. This would

include indirect comparisons utilised (i.e., A vs B and B vs C to determine A

vs C where there is no statistical adjustment for B))

iii. Interrupted time series without a parallel control group


33

f. Level IV: Case series with either post-test or pre-test/post-test outcomes.

Overall strength

A judgment was made about the strength of the evidence base, taking into account quality and

risk of bias, quantity of evidence, and level of evidence. Three independent raters rated the

strength of the evidence base, and together reached a consensus agreement on an overall rating

using the following categories:

High strength

One or more level I studies

with a low risk of bias OR

three or more level II studies

with a low risk of bias

Moderate strength

One or two level II

studies with a low

risk of bias OR two or more

level III studies with a low risk

of bias

Low strength

One or more level I to level

IV studies with a high risk of

bias

1

Direction

The direction component of the ranking system makes a judgment as to whether the results are

in a positive or negative direction. In cases where there are trials that show findings in different

directions, preference is given to the direction of the trial findings with the highest level and best

quality.

Positive direction

The weight of the evidence

indicates positive results

Unclear direction

The evidence does not show

significant effects OR the

results are mixed

Negative direction

The weight of the evidence

indicates negative results

1

Consistency

The consistency component of the ranking system of the body of the evidence assesses whether

the findings are consistent across the included trials (including across a range of trial populations

and trial designs). It is important to determine whether trial results are consistent to ensure that

the results are likely to be replicable or only likely to occur under certain conditions.

1

1

1

1


All studies are

consistent reflecting

that results are highly

likely to be replicable

Most studies are

consistent and

inconsistency may

be explained,

reflecting that results

are

moderatelyhighly

likely to be replicable

Some inconsistency


are somewhat

unlikely to be

replicable

All studies are

inconsistent


are highly unlikely to

be replicable

34

Generalisability

This component covers how well the participants and settings of the included trials could be

generalised to the target population. Population issues that might influence this component

included gender, age or ethnicity, or level of care (e.g., community or hospital).

The population/s

examined in the

evidence are the

same as the target

population

The population/s

examined in the

evidence are similar

to the target

population

The population/s

examined in the

evidence are

different to the target

population, but it is

clinically sensible to

apply this evidence

to the target

population

The population/s

examined in the

evidence are not the

same as the target

population

Applicability

This component addresses whether the evidence base is relevant to the Australian context, or to

specific local settings (such as rural areas or cities). Factors that may reduce the direct

application of trial findings to the Australian context or specific local settings include

organisational factors (e.g., availability of trained staff) and cultural factors (e.g., attitudes to

health issues, including those that may affect compliance).

Directly applicable to

the Australian

context

Applicable to the

Australian context

with few caveats

Applicable to the

Australian context

with some caveats

Not applicable to the

Australian context


35

Ranking the evidence

On balance, this next step takes into account the considerations of the strength of the evidence

(quantity and risk of bias, quantity of evidence and level of evidence), consistency,

generalisability and applicability. The total body of the evidence is then ranked into one of four

categories: ‘Supported’, ‘Promising’, ‘Unknown’ and ‘Not supported’ (see Figure 1). Agreement

on ranking is sought between three independent raters.

NOTE: If the strength of the evidence was considered to be low, the next steps of rating

consistency, generalisability, and applicability were not conducted and the evidence was rated as

‘Unknown’.

SUPPORTED

Clear, consistent evidence of

beneficial effect

PROMISING

Evidence suggestive of

beneficial effect but further research

required

UNKNOWN

Insufficient evidence of beneficial effect

and further research is required

NOT SUPPORTED

Clear, consistent evidence of no

effect or negative / harmful effect

Figure 1: Categories within the intervention ranking system


36

Results

The following section presents the flowcharts relating to the number of records identified at each

stage of the REA (refer to Figure 2 and Figure 3). From all of the sources searched, a total of 50

papers (48 original trials) were identified.

For question one which examined meditation and yoga, 29 original trials were identified as

meeting the inclusion criteria, as well as two additional secondary analyses, creating a total of 31

papers. For question two which examined mindfulness, 19 original trials were identified as

meeting the inclusion criteria. Of the 48 original trials, 10 papers were separated out and used to

answer question three, which examined adjunct treatments. This is explained in further detail in

the Methods section.

Approximately half (n = 26) of the trials originated from the US. There were three from Canada,

two each from Sweden, Iran, India, Germany, the UK, and the Netherlands, and one each from

Columbia, Taiwan, Croatia, Austria, Hong Kong, Vietnam, and Australia. All trials were published

between 2010 and 2018. The secondary analyses were based on two separate US trials.

Approximately 80% of the trials were published in the last five years, with the remainder

published prior to 2014.

It should be made clear that varying inclusion criteria were applied to each section of the review.

Question one examined the role of meditational practices including meditation, mantra, and yoga

in mental health treatments for PTSD, depression, anxiety, and AUD. It included RCTs that

compared these interventions to any comparison (pharmacotherapy, therapy, control, or waitlist

conditions). In order to be considered a significant finding of beneficial effect, those receiving the

meditation or yoga-based intervention were required to show greater improvement in primary

outcomes than those in a non-active comparison group, or non-inferiority to active comparison

group.

For the second question, which examined the available evidence relating to mindfulness

interventions, inclusion criteria specified that the comparison group must be a conventional

psychological or pharmacological treatment for PTSD, depression, anxiety, or AUD. As such, in

order to be considered as showing a beneficial effect, mindfulness interventions were required to

be just as good as the conventional treatments, that is, demonstrate non-inferiority to

conventional treatment.

The third question investigated the use of both meditational and mindfulness interventions as

adjunct to conventional psychological or pharmacological treatment of PTSD, depression,

anxiety, and AUD. In order to be considered to have a beneficial effect, those receiving the

adjunct meditational or mindfulness interventions were required to have significantly greater

improvement than the comparison group on the outcome of interest. That is, these trials were

required to demonstrate a benefit from the addition of meditation, yoga or mindfulness to other

psychological or pharmacological treatment.


Total records retrieved through

database search

(n=13,574)

Records screened on title and

abstract

(n=4,719)

Full-text articles assessed for

eligibility

(n=199)

Number of papers included in final

reports

(n=31)

(n=28, plus 1 additional paper* and 2

secondary papers)

Iden

tifi

ca

tio

n

Scre

en

ing

E

lig

ibilit

y

Inclu

ded

Duplicates excluded

(n=8,855)

Full text articles excluded due to

ineligibility

(n=169)

Excluded for failure to meet inclusion criteria associated with:

Population (n=79)

Study design (n=59)

Intervention (n=16)

Outcomes (n=13)

Comparison (n=2)

Title and abstract records

excluded

(n=4,520)


Intervention (n=1,047)

Not peer reviewed (n=919)

Not a treatment (n=871)

Population (n=679)

Prior to 2010 (n=344)

Study design (n=290)

Duplicate (n=142)

Qualitative study (n=71)

Commentary (n=53)

Outcomes (n=47)

Protocol only (n=47)

Amendment only (n=9)

Text not in English (n=1)

Question 1 (n=25)

Question 3 (n=6)

Figure 2: Flowchart representing the number of records retrieved during search for

meditation and yoga trials

*Paper published during draft stage of the final report

37


Total records retrieved through

database search

(n=2,766)

Records screened on title and

abstract

(n=857)

Full-text articles assessed for

eligibility

(n=137)

Number of papers included in final

reports

(n=19)

(n=17, plus 2 additional papers

located via hand search)

Iden

tifi

ca

tio

n

Scre

en

ing

E

lig

ibilit

y

Inclu

ded

Duplicates excluded

(n=1,909)

Full text articles excluded due to

ineligibility

(n=119)


Population (n=62)

Study design (n=33)

Comparison (n=18)

Outcomes (n=4)

Intervention (n=2)

Question 2 (n=15)

Question 3 (n=4)

Title and abstract records

excluded

(n=720)

Excluded for failure to meet inclusion criteria associated

with:

Outcomes (n=279)

Population (n=201)

Intervention (n=82)

Study design (n=73)

Not peer reviewed (n=41)

Commentary (n=19)

Amendment Only (n=13)

Not a treatment (n=8)

Qualitative study (n=3)

Mixed Method study (n=1)

38

Figure 3: Flowchart representing the number of records retrieved during search for

mindfulness trials

)

Text not in English (n=1)


39

Summary of the Evidence

A total of 50 articles were included in this review. Thirty-one articles examined the use of

meditation and yoga for the treatment of PTSD, depression, anxiety, and AUD, and 19 articles

examined the use of mindfulness for the treatment of PTSD, depression, anxiety and AUD. Of

the 50 articles, 10 articles examined the use of adjunct meditation, yoga, and mindfulness

interventions for the treatment of PTSD, depression, anxiety, and AUD. A detailed summary of

the trials is found in the evidence profile presented in Appendix 4, and in Appendix 5 as a brief

overview.

Stand-alone meditation and yoga treatments

Meditation interventions

The first research question aimed to investigate the use of meditational and yoga interventions to

treat PTSD, depression, anxiety, and AUD. These were examined in relation to any comparison

groups, such that in order to be considered a ‘Supported’ intervention, it was required to be more

effective than any comparison condition (pharmacotherapy, therapy, assessment-only, or waitlist

conditions).

Group-based meditation for PTSD (compared to non-active comparison)

Only one trial investigated the effectiveness of group-based meditation to treat PTSD, compared

to a non-active comparison.107 The large single-blind RCT compared a group-based mantram

repetition program combined with treatment as usual (TAU) to TAU only. The sample consisted

of 146 outpatient veterans with a diagnosis of PTSD. The intervention group received six 90-

minute weekly group meditation sessions, which included PTSD psychoeducation and

instructions on how to choose and utilise a mantram to manage symptoms. The comparison

group participants received case management as needed, in order to monitor their mental health

and current treatment, as well as adherence to medication and access to future treatments. Both

groups continued with any pre-existing medication regimens. Both self-reported and clinician-

rated PTSD symptoms had significantly greater reductions in the intervention group compared to

the comparison group. Amongst the participants who took part in the meditation intervention, 24

per cent demonstrated clinically significant reductions on the clinician-rated PTSD measure post-

intervention, compared to 12 per cent of the comparison group. The intervention group showed

further reductions in PTSD symptoms at the six-week follow-up assessment, but a comparison

with the comparison group was not possible as they were participating in the mantram

intervention at this time point. Low drop-out rates were observed in both the intervention group

(7%) and the comparison group (6.7%), indicating that this intervention was acceptable to


40

individuals with PTSD. However, the inability to compare outcomes from the intervention group

to the comparison group at the six-week follow-up assessment limited findings being made on

the short-term effects of this treatment. Additionally, an overrepresentation of male participants

(97%) limited generalisability of the results to females. In general, however, this was a well

conducted trial that provides important preliminary findings regarding the effectiveness of

mantram meditation in treating PTSD.

While the single trial examining group-based meditation interventions to treat PTSD used a large

sample, given that it was the only trial, the strength, direction, consistency, and generalisability of

the evidence were not rated. Therefore, the body of evidence for group-based meditation as a

treatment for PTSD, compared to any control condition, was ranked as ‘Unknown’.

Group-based meditation for PTSD (compared to active comparison)

One notable study was published in the Lancet Psychiatry journal in late 2018. The trial

investigated the use of group-based transcendental meditation (TM) as a treatment for PTSD.108

It included 203 US veterans from the VA San Diego Healthcare System diagnosed with PTSD,

and compared three 12-week interventions: TM, prolonged exposure (PE) and PTSD health

education. The TM intervention was delivered in groups, with five sessions of teaching TM

technique, seven maintenance sessions, and encouragement to practice two 20-minute sessions

at home daily. This intervention was compared to PE, which is currently one of the most widely

accepted first-line treatments for PTSD. There was also a third group that included participants

who received 12 sessions of PTSD health education following manualised instructions. Mean

changes in PTSD symptoms at the end of the 12 weeks was greater for both the TM group and

the PE group compared to the health education group. TM was found to be significantly non-

inferior to PE in reducing clinician-rated and self-reported PTSD scores. Within the TM group,

61% of participants displayed clinically significant change, compared to 42% in the PE group and

32% in the health education group. Particularly noteworthy within this trial was the finding that

when examining clinically significant change on clinician-rated PTSD scores, the TM group

demonstrated a significantly higher percentage of change than the health education group, but

the PE group did not display a significantly higher percentage of change than the health

education group. However, when examining clinically significant symptom reduction using the

self-report measures, both TM and PE had greater rates of change than the health education

group. This trial provides some evidence that the benefits of TM are comparable to those of PE,

indicating its potential as a viable alternative treatment. The trial had some limitations, including

five significant adverse effects reported, which included suicide attempts, death (non-suicidal),

drug overdose, and illness. However, none of these were concluded to be related to any

treatments received in the trial. In addition, generalisability of findings was limited due to the

sample of primarily male veterans with a baseline level of severe PTSD. Therefore, it is unknown

of the results could be generalised to females and those with mild or moderate levels of PTSD.


41

High attrition rates in the PE group (38%) and the TM group (25%) also served as a potential

limitation. Overall, however, this was a well-conducted and rigorous study that provided

important findings with regard the use of meditation to treat PTSD, particularly in comparison

with a well-supported conventional treatment.

Due to there only being one trial examining group-based meditation as a treatment for PTSD (in

comparison to an active comparison condition), the strength, direction, consistency,

generalisability, and applicability of this evidence could not be ranked. Therefore the body of

evidence of group-based meditation as a treatment for PTSD, compared to active comparison

conditions, was ranked as ‘Unknown’.

Individual meditation for PTSD (compared to an active comparison)

Bormann and colleagues, who conducted the previously mentioned trial using mantram

meditation to treat PTSD, extended their research to examine effects of the same intervention

delivered in an individual format.109 The trial included 173 patients from the US Veteran Health

Administration (VHA), 89 of whom received the mantram repetition program via one-on-one

weekly sessions and 84 of whom received present-centred therapy (PCT). Both the mantram

and the PCT groups experienced clinically significant improvements in clinician-rated PTSD

scores, and individuals who received the mantram intervention had significantly greater

improvement compared to those who received PCT, both post-treatment and at two-month

follow-up. Self-reported PTSD scores showed a significant difference between the groups post-

treatment, with the mantram group showing greater symptom reduction, but there was no

significant difference between groups at the two-month follow-up assessment. The discrepancy

in clinician-rated and self-reported scores at follow-up suggests the long-term benefits of

mantram meditation compared to PCT are somewhat unclear, but short-term improvement in

PTSD symptom severity was consistent across the two measures. Within the mantram group, 59

per cent of participants no longer met criteria for PTSD at the two-month follow-up, which was

significantly greater than the 40 per cent that no longer met criteria within the PCT group. Four

adverse events were reported (substance abuse relapse and inpatient detoxification), but were

determined by authors to be unrelated to the trial treatment. This was a well-designed trial with

few methodological flaws, except for the fact that it included a higher proportion of males than

females, which potentially limited the degree of generalisability to females. There was also a

slightly higher drop-out rate in the mantram group (22%) compared to the PCT group (14%),

however this difference was not found to be significantly different and thus was not attributed to

the treatment.

The strength, direction, consistency, generalisability, and applicability of this evidence could not

be ranked due to there being only one trial, despite it containing a large sample and being well


42

conducted. Therefore the body of evidence investigating individual meditation as a treatment for

PTSD, compared to any comparison condition, was rated as ‘Unknown’.

Group-based meditation for depression (compared to a non-active comparison)

A single RCT examined a group-based meditation intervention for the treatment of depression

amongst older adults between the ages of 60 and 85.110 Participants (N = 51) were allocated to

either automatic self-transcending meditation (n = 26) or a waitlist TAU condition (n = 25). This

form of meditation differs from previously described forms by drawing attention inward to

promote mental and physical relaxation. Although it utilises a mantram, it differs from mantram

meditation in that the goal is to transcend the mantram rather than sustain focus on it. This was

implemented via four group meditation sessions followed by weekly reinforcement sessions that

encouraged daily practice of meditation at home. Participants in the comparison group continued

TAU (ongoing therapy and/or antidepressants), and were offered the opportunity to receive the

meditation training after the trial. Both primary and secondary measures of depressive symptoms

were significantly reduced in the meditation condition compared to the TAU group. Quality of life

improved throughout the trial period in both conditions as well. The dropout rate was 18 per cent

across both groups. Given that this was the only trial on meditation as a treatment for

depression, it should be noted that the findings may not be representative of the effects of all

types of meditation on depressive symptoms. While this in itself is not a limitation of the trial, it

reduces the generalisability of its findings to the body of evidence.

As there was only one trial identified which examined group-based meditation as a treatment for

depression, the strength of evidence, as well as the direction, consistency, generalisability, and

applicability of the evidence were not rated. Therefore, the overall body of evidence for

meditation as a treatment for depression, compared to any comparison condition, was ranked as

‘Unknown’.

Individual meditation for depression

There were no trials identified which used individual meditation for the treatment of depression.

Group-based meditation for anxiety

There were no trials identified which used group-based meditation for the treatment of anxiety.

Individual meditation for anxiety

There were no trials identified which used individual meditation for the treatment of anxiety.


43

Group-based meditation for combined depression and anxiety

There were no trials identified which used group-based meditation for the treatment of combined

depression and anxiety.

Individual meditation for combined depression and anxiety

There were no trials identified which used individual treatment for the treatment of combined

depression and anxiety.

Group-based meditation for AUD

There were no trials identified which used group-based meditation for the treatment of AUD.

Individual meditation for AUD

There were no trials identified which used individual meditation for the treatment of AUD.

Yoga interventions

Group-based yoga for PTSD (compared to a non-active comparison)

Five RCTs reported on the use of yoga as a treatment for PTSD, all of which used group formats

to deliver the interventions.10,11,111-113

The first RCT included 100 ex-combatants from illegal armed groups in Columbia being

reintegrated after having been exposed to local armed conflicts.112 Half were allocated to weekly

classes of Satyananda yoga (n = 50) and the remaining half continued with the standard

demobilisation program, which consisted of monthly appointments with a psychologist (n = 50).

There was a large effect size for the reduction in PTSD symptoms between pre-intervention and

one-month post-treatment within the yoga group (d = 1.15), whereas the comparison group

demonstrated a medium effect size (d = 0.42). When symptom clusters of PTSD (re-

experiencing, avoidance, and hyperarousal) were analysed separately, the yoga group also

demonstrated reductions on those symptom cluster scores with large effect sizes. The post-

intervention assessments at one month indicated that the mean PTSD symptom severity for the

yoga group was below the clinical threshold for diagnosing PTSD, whereas for the comparison

group the mean score was above this threshold. Although the dropout rate was only 10 per cent,

there was no intention-to-treat analysis conducted, which introduced some risk of bias to the

findings. In addition to this, while it was a relatively well conducted trial, it was limited somewhat

by a lack of generalisability, attributed to a male-dominated sample as well as a unique sample

of ex-combatants from illegal armed groups. This may limit the extent to which these findings can

be generalised to females or traditional military populations.


44

A second trial investigated the effectiveness of Sudarshan Kriya yoga on US male veterans with

symptoms of PTSD, using a small RCT with 21 participants.11 Although this trial did not stipulate

clinically diagnosed PTSD within its inclusion criteria, mean self-report PTSD scores for both the

intervention and waitlist groups were above the suggested clinical cut-off to diagnose PTSD. The

intervention consisted of daily three-hour group yoga sessions for a period of seven days, while

the comparison was a waitlist group that received the same intervention at a later date.

Participants also continued with pre-existing treatments. Results of the trial showed significantly

lower PTSD scores for the yoga group compared to baseline at post-intervention, one month

post-intervention, and one year post-intervention. The differences between groups at post-

intervention, one-month follow-up, and one-year follow-up all showed large effect sizes,

indicating a large magnitude of difference between groups in favour of the yoga group. While the

trial was well conducted and had a low dropout rate (5%), it was limited by a small sample size of

21 participants. The sample was also limited to male participants. The small sample size

introduced a degree of risk of bias, while the male-only sample limited generalisability of the

findings to females.

Another small RCT (N = 38) investigated a Kripalu-based yoga intervention and compared it to

an assessment-only comparison group.111 The intervention involved 75-minute yoga and

assessment sessions that could be done weekly over 12 weeks or twice-weekly over six weeks.

Both the yoga and comparison groups had significant reductions in PTSD scores through the

course of the intervention, however, there was no significant difference between the groups. A

secondary analysis of this trial114 found reductions in alcohol use amongst the yoga group, but

this was not statistically significantly different from the comparison group. Thirty-two per cent of

participants withdrew from the trial or were lost to follow-up. A female-only sample limited the

generalisability of the trial’s findings to males, and the small sample size increased the risk of

bias.

Two more RCTs examined yoga as a treatment for PTSD but both were limited by high attrition

rates.10,113 One Canadian trial compared an eight-week Kundalini yoga intervention to a waitlist

comparison group (N = 80).10 Participants in this trial were permitted to continue concurrent

outside treatment if it did not include a contemplative component. Results indicated lower self-

reported PTSD scores in the yoga group compared to the comparison group post-intervention. A

high drop-out rate of 51 per cent was reported for the yoga group, which was considerably higher

than the overall drop-out rate for both groups (30%). The reasons for drop-out in the yoga group

that were provided included scheduling conflicts, medical and health reasons, and personal

reasons. This was likely to have introduced bias into the trial results. In addition, the lack of an

intention to treat analysis introduced another potential source of bias, especially considering the

high drop-out rate, as it limited the amount of interpretable data. The other RCT included 51 US

veterans and active duty military personnel diagnosed with PTSD, who were randomly assigned


45

to receive a ten-week Kripalu yoga intervention or to a waitlist group.113 Results of the trial

showed reductions in clinician-rated PTSD severity for both groups, with no significant between-

group differences. There were no statistically significant differences between groups for self-

report PTSD symptoms. The only group that showed significant reductions in clinician-reported

and self-reported PTSD scores was the waitlist group that received the yoga intervention after

the original intervention group, although results should be considered in light of the small sample

size for this group (n = 7). In the original yoga group, 61 per cent (n = 16) of the randomised

participants dropped out or were lost to follow-up, and 16 per cent (n = 4) of the waitlist group

dropped out. This attrition rate was explained by authors as the potential result of a long trial

period (10 weeks), with the recruitment process slowed down by needing to wait for sufficient

numbers to start yoga groups.

Although there was one relatively well conducted trial,112 the strength of this group of evidence

was rated as low. Several of the trials had methodological limitations such as small sample sizes

and high attrition rates. While all trials indicated that yoga interventions were associated with

improvements in PTSD symptoms, not all reported these improvements as being greater than

that of comparison groups, indicating an unclear direction of evidence. The inconsistencies in

sample size, follow-up assessments, and varying sample populations suggested that the results

are somewhat unlikely to be replicable. While all participants were recruited from the general

population, three of the five trials included only male samples, which limited the degree to which

findings could be considered reflective of the general adult population. The evidence was,

however, considered directly applicable to the Australian context. Overall, it was judged that

although the evidence suggests some benefit of group-based yoga as a treatment for PTSD

when compared to any comparison condition, there is a lack of well supported findings, and

therefore it is rated as ‘Unknown’.

Individual yoga for PTSD

No trials were identified which used individual yoga as a treatment for PTSD.

Group-based yoga for depression (compared to a non-active comparison)

Six RCTs investigated the use of group-based yoga as a treatment for depression.115-121 It should

be noted that the trials included participants from specific samples, with five of the six trials

including only female participants, and three of these being conducted with pregnant females to

examine the effectiveness of yoga on pre-natal or post-natal depression. While this is not a

limitation of these trials, it somewhat reduces the generalisability of findings to the general

population.

The first trial (the only one with a mixed gender sample) was a small RCT (N = 38) implementing

an eight-week Hatha yoga intervention with twice-weekly classes.120 The comparison group


46

attended the same number of group sessions, but received an education module on historical

figures of the yoga tradition instead of yoga classes. Adults with mild-to-moderate depression

were recruited from local community and outpatient clinics. Those in the yoga group displayed a

significantly greater reduction in depressive symptoms compared to the comparison group.

Amongst those who completed the eight-week yoga intervention, 60 per cent achieved remission

from depressive symptoms, while 10 per cent of the comparison group achieved remission. Two

adverse events were reported (musculoskeletal injuries) but were not related to the yoga

exercises, and additional reports of musculoskeletal discomfort during yoga classes resolved

throughout the course of the intervention. Limitations of this trial include a small sample size, as

well as a relatively high drop-out rate of 35 per cent, both of which introduced risk of bias to the

findings. Those who dropped out of the trial did so for a variety of reasons such as scheduling

conflicts and family emergencies, none of which were considered to be related to the

intervention.

Another RCT investigated the use of Hatha yoga with 26 adult females with mild to moderate

depression in Taiwan.116 The yoga group (n=13) participated in twice-weekly, 60-minute group

yoga classes over 12 weeks. The waitlist comparison group (n=13) was instructed not to engage

in any yoga practice and maintain usual levels of physical activity, and was provided with the 12-

week yoga program after the post-intervention assessment. Depressive symptoms were

significantly reduced at post-intervention within the yoga group, while the comparison group

showed no significant change. These results should be considered in light of the small sample

size, from which 23 per cent dropped out, and also the limitation to females with mild or

moderate depression. Therefore, there may be limited generalisability to a general population of

adults with severe depression.

One small US RCT, published in 2013, consisted of a Hatha yoga treatment for 27 women

diagnosed with Major Depressive Disorder (MDD) or dysthymia (N=27).118 A subsequent paper,

published in 2014, reported on the results of a one-year follow-up assessment of the trial

participants.119 Participants were randomised to weekly 75-minute group yoga classes and

instructed to practise at home daily (n = 15) or to attend weekly 75-minute group health

education classes as a comparison condition (n = 12). Results indicated no significant difference

in reductions in depression severity between the yoga group and the comparison group, but all

participants had reduced levels of depression severity over the course of the eight-week trial.

Rumination was the only outcome that displayed greater reduction in the yoga group than in the

comparison group. At the 12-month follow-up,119 participants from both the yoga and comparison

groups (N = 9) showed decreases in depression severity, with the yoga group showing a

significantly greater reduction in depression severity and rumination. While the long-term follow-

up provided valuable information, this trial was limited by a small sample size and high attrition

rate, both in the primary analysis (33%) and in the one-year follow-up analysis (66%).


47

The three remaining RCTs targeting depression had samples consisting of pregnant females or

females who had recently given birth.115,117,121 Considering that the diagnosis and treatment for

pre-natal and postpartum depression do not differ from that of MDD, it is reasonable to consider

these trials alongside the previous trials reporting on depression. The first of these trials involved

a gentle Vinyasa flow yoga intervention for females with postpartum depression who had given

birth within 12 months and met criteria for MDD (N = 57).115 The yoga group (n = 28) was

compared to a waitlist comparison group (n = 29) which received the same treatment at a later

time. Participants were identified and recruited using US public birth records and local

advertisements. Clinician-rated depressive symptoms decreased significantly for both groups,

but the difference was significantly greater in the yoga group compared to the comparison group.

In the yoga group, 78 per cent of participants displayed clinically significant change at the post-

treatment assessment, compared to 59 per cent of participants in the comparison group. There

was an 11 per cent dropout rate across both groups, which was not judged to be dependent on

group allocation.

The remaining two trials examined the effectiveness of yoga treatments on pre-natal depression

amongst pregnant females.117,121 One small RCT included 20 women who were recruited from

community locations and obstetrician-gynaecologist (OB/GYN) practices in the US.121 Women

who were 12-26 weeks’ pregnant with minor or major depression were randomised to a pre-natal

yoga program (n = 12) or a mom-baby wellness workshop as the comparison group (n = 8). Both

conditions involved weekly 75-minute classes for nine weeks, with the yoga group provided with

pre-natal yoga classes and the comparison group given group workshops on postpartum health

and wellness. Depression severity improved in both groups, on both the self-report and clinician-

rated measures. The yoga group had greater reductions in both measures, but the difference

between the yoga and comparison groups was not statistically significant. The trial had several

methodological limitations that affected the degree to which its results could be considered

interpretable. The randomisation method was not described, which created a potential for biased

results if it was not properly conducted. Blinding was also not mentioned despite the use of a

clinician-rated depression measure. In addition to a standardised clinician-rated measure for

depression, the Edinburgh Postnatal Depression Scale (EPDS) was also used to monitor

symptoms of depression, despite it being a diagnostic tool. It is often used to measure distress in

pregnant females, but the fact that it was used to measure symptoms of depression in this trial

may be a limitation. The drop-out rate was low (10%), but intent-to-treat analysis was not utilised

to replace the missing data, thus further reducing the data available for analysis. These

limitations, combined with the small sample size and lack of generalisability stemming from a

sample made up only of pregnant females, limited the interpretability of the findings.

A second RCT examining yoga as a treatment for 84 females with pre-natal depression involved

three conditions: a yoga intervention with twice-weekly 20-minute group yoga sessions, massage


48

therapy with twice-weekly 20-minute massages, or a standard pre-natal care comparison

group.117 Results indicated significant reductions in depression and anxiety in both the yoga

group and the massage groups, but no statistical analyses were conducted to compare the

effectiveness of the interventions, thus preventing any meaningful inferences to be made from

this trial.

The strength of the evidence for group-based yoga for depression was rated as moderate. Of the

six trials identified, there were three trials that, despite having some methodological flaws such

as lack of long-term follow-up data or relatively small sample sizes, were otherwise well

conducted.115,116,120 The three remaining trials117-119,121 had methodological limitations that

included small sample sizes, high drop-out rates, lack of adequate randomisation, and lack of

assessor blinding. All trials reported that yoga was associated with improvements in depressive

symptoms, but not all indicated that this improvement was significantly greater than that of

comparison groups. It is relevant to note that the higher quality trials consistently showed greater

improvement in yoga groups than in comparison groups, while the trials showing no significant

differences between yoga and comparison groups were found to have considerable

methodological limitations. The direction of the evidence was therefore assessed to be positive.

It was also judged that most trials were consistent, and that inconsistencies could be explained,

in this case by poor methodology. As such, the results were considered somewhat likely to be

replicable. The generalisability of the evidence to the target population was somewhat limited

due to five of the six trials being conducted with female participants only and three including

females with pre-natal or postpartum depression. The evidence was, however, judged as directly

applicable to the Australian context. Although generalisability was limited, the strength, direction,

consistency, and applicability of the evidence indicated that the findings were noteworthy. The

evidence was thus suggestive of the beneficial effects of group-based yoga to treat depression

when compared to any comparison condition, but further well conducted research is also

required. Overall, the body of evidence for group yoga as a treatment for depression was ranked

as ‘Promising’.


There were no trials identified which used individual meditation as a treatment for depression.

Group-based yoga for anxiety

There were no trials identified which used group-based yoga as a treatment for anxiety.

Individual yoga for anxiety (compared to non-active comparison)

There was one trial that investigated individual yoga as a treatment for situational anxiety within

the context of surgery.122 The RCT used sukha pranayama breathing exercises in patients before


49

they underwent coronary angiographies. Eighty participants recruited from a hospital in Iran, all

of whom were about to undergo coronary angiographies, were randomised to a group conducting

sukha pranayama breathing for five minutes (n=40), or a comparison group consisting of routine

coronary angiography-related care (n=40). In order to qualify for inclusion in the trial, patients

were required to be undergoing the surgery for the first time and have an anxiety score of 43 or

greater on the State-Trait Anxiety Inventory (STAI). Assessments were conducted before, half an

hour post, and one hour post-intervention or standard care. The intervention group displayed

significant reductions in anxiety symptoms half an hour and one hour after the breathing

exercises, while the comparison group displayed slight but not statistically significant decreases.

Between-group differences in anxiety scores at half an hour and one hour post-intervention were

both significant. This trial differed from most other trials in this report due to being a brief single-

session intervention, compared to the multiple session treatments offered in other trials. As such,

its efficacy as a single intervention was difficult to compare to longer-term interventions. There

was no long-term follow-up to determine if decreases in anxiety symptoms were sustained, or if

patients continued to practise breathing exercises. It was also conducted with patients

undergoing coronary angiography and thus might not represent the same results as it would with

otherwise healthy adults. This trial did, however, highlight the potential effectiveness of a single

session of yoga exercises to relieve situational anxiety related to a specific event.

As there was only one trial examining yoga as a treatment for anxiety, the strength, direction,

consistency, generalisability, and applicability of the evidence were not rated. Therefore, the

body of evidence for individual yoga as a treatment for anxiety when compared to any

comparison condition was ranked as ‘Unknown’.

Group-based yoga for combined depression and anxiety (compared to non-active

comparison)

There were four RCTs that examined the use of group-based yoga as a treatment for combined

depression and anxiety.13,123-125 These trials included mixed populations of individuals suffering

from depression, anxiety, or both. Most of these trials did not report results separately for the two

disorders, making it difficult to determine if the intervention was more effective at treating

depression or anxiety. Rather, the trials aimed to examine group yoga’s efficacy as a treatment

for both depression and anxiety.

The first trial included 46 pregnant females suffering from symptoms of depression or anxiety.123

They were randomised to either Ashtanga Vinyasa yoga (n = 23) or TAU (n = 23). Both groups

were permitted to continue TAU external to the trial for depression and/or anxiety. There were no

restrictions on the care received outside the trial, but participants were asked to provide

information about it. Most commonly this included therapy or antidepressants, but no significant

difference was found between these groups of participants. There was no significant difference in


50

the improvement of the yoga group and that of the comparison group in depressive symptoms,

and both state and trait anxiety but both groups demonstrated significant improvement in

depression scores over time. This was also the case for state and trait anxiety scores. A

measure of negative affect indicated that there was a greater reduction in scores in the yoga

group compared to the TAU group. This suggests that while the yoga intervention was not more

effective than TAU in reducing depression and anxiety symptoms, it reduced negative affect to a

significant degree. There was also a high retention rate for the yoga group (87%), as well as a

relatively low dropout rate of 11 per cent. One adverse outcome was reported, in the form of

premature labour, but this was not linked to the yoga intervention. The trial’s limitations included

a small sample size, and a lack of analysis by disorder meaning it is impossible to isolate the

effects of the intervention on each condition. In addition, the lack of follow-up assessment mean

that the long-term effects of the intervention are unknown.

A large RCT investigating the effectiveness of yoga, mindfulness, and a waitlist comparison

group on depression and anxiety symptoms (N = 90) included adult students with a diagnosis of

anxiety and/or depression recruited from a US university.124 The participants were randomised to

a Hatha yoga intervention group (n=23), a mindfulness intervention group (n=21), or a waitlist

comparison group (n=23). Both intervention groups consisted of weekly 75-minute group classes

for eight weeks, while the comparison group completed only assessments and had the option to

be waitlisted for the intervention that demonstrated the best outcomes after the trial. Self-

reported depression, anxiety, and stress symptoms reduced significantly in the yoga group, as

well as in the mindfulness group between pre-intervention and post-intervention. Both groups

also showed significantly greater symptom reduction than the comparison group. Scores

remained similar at the 12-week follow-up assessment. This may be explained by participants

not continuing to engage in yoga practices after completion of the trial, or their depression and

anxiety symptoms having reached a level of stability. Due to a lack of statistical tests comparing

the yoga and mindfulness groups, it was not possible to determine if yoga was more effective

than mindfulness in reducing symptoms of depression and anxiety. A 20 per cent attrition rate

was recorded, but was attributed to several different reasons, including conflicting work or study

demands, students leaving the university, or discontinuing after the first yoga session. The

sample consisted of 85 per cent females, which limited the degree of generalisability of the

findings to the general population. Another limitation was the lack of reporting of baseline group

characteristics of the study sample. Although a verified randomisation process was described, it

was not possible to determine how effective the randomisation was without examining the

baseline similarities between the study groups.

Two additional RCTs examining yoga as an intervention for depression and anxiety showed

mixed results, although both were limited by several methodological flaws.13,125 One small RCT

(N = 30) implemented an twice-weekly eight-week yoga intervention targeted at reducing


51

symptoms of both depression and anxiety.125 The comparison group involved participants

receiving an informational pamphlet and twice-weekly newsletters about chronic low back pain.

Participants had chronic low back pain and diagnoses of both depression and anxiety. Results

showed significant differences between the groups, with the yoga group having significant

reductions in depression scores, while the comparison group did not. The findings suggested

that this yoga intervention was effective in reducing symptoms of depression but not anxiety. The

small sample size as well as an unidentified randomisation process limited the degree of

confidence in the findings. Dropouts were also not reported, thus preventing inferences regarding

tolerability of the intervention or reliability of the findings. Another relatively large RCT (N = 150)

examined yoga nidra in addition to pharmacotherapy as a treatment for depression and anxiety

in women with menstrual irregularities, comparing it to pharmacotherapy only13 Results indicated

significant improvement only in participants who reported mild or moderate anxiety and

depression, whereas those who started the trial with severe symptoms did not show significant

improvement after six months. This trial had a number of methodological limitations, including an

improper randomisation process, no assessor blinding despite using clinician-rated measures of

depression and anxiety, as well as lack of intention-to-treat analysis and a relatively high dropout

rate in the yoga group (23%, compared to 15% in the comparison group). It was also unclear

whether the pharmacotherapy prescribed to both groups was targeting psychological symptoms

or the menstrual irregularity. Due to the methodological limitations, the mixed results of these two

trials are difficult to interpret.

The strength of evidence for group-based yoga to treat combined depression and anxiety was

rated as low. Trials suffered from limitations including small sample sizes, lack of blinded

assessment, high attrition rates, or did not document group similarity at baseline. As such, the

trials were considered to have a considerable risk of bias. Inconsistency in the results suggested

that the results are highly unlikely to be replicable. Although generalisability of the findings was

somewhat limited, the results were still considered clinically sensible to apply to the target

population because they covered a broad range of samples and comorbid conditions. The

evidence was also considered to be directly applicable to the Australian context. However, due to

the low strength, unclear direction, and low consistency of the evidence, the efficacy of group-

based yoga as a treatment for combined depression and anxiety, when compared to any

comparison condition, was ranked as ‘Unknown’.

Individual yoga for combined depression and anxiety (compared to a non-active

comparison)

An Australian RCT (N = 107) evaluated the effectiveness of an individual yoga intervention to

treat heterogeneous samples with depression and/or anxiety, comparing it to a TAU waitlist

condition in which participants could continue ongoing treatment including therapy, counselling,

psychotherapy, or medications.126 At the six-week follow-up assessment, a statistically significant


52

difference was observed between the yoga and waitlist on depression scores, in favour of the

yoga group. A low dropout rate of nine per cent was a strength of the trial. Trial measures were

all self-reported which may have introduced reporting bias. As with the evidence from the

previous category, it was not possible to distinguish the extent to which the yoga intervention

implemented in this trial targeted depression, anxiety, or comorbidity or both.

The strength of the evidence for individual yoga interventions as a treatment for depression and

anxiety when compared to any comparison condition was found to be low, based on a single

trial. The body of evidence was therefore ranked as ‘Unknown’.

Group-based yoga for AUD (compared to a non-active comparison)

There was one trial that examined the use of group-based yoga to treat AUD, which used a

cross-over RCT design with a single intervention session of yoga-gymnastics, Nordic walking, or

passive control (sitting and reading magazines) with 16 participants.127 Participants were

inpatients diagnosed with alcohol dependence and clinically observable cravings, but currently

abstinent. Participants completed all three interventions in randomised orders, with a period of

one week between the 60-minute sessions. Only one participant dropped out (6%), reportedly

due to acute illness. Results from the trial indicated no significant changes in alcohol cravings

after any of the three interventions. Due to the nature of the trial, which included only single

interventions of yoga, it was not possible to determine if a longer period of treatment would have

led to better results. The trial also included a disproportionately low number of female

participants, as 80 per cent of the participants were male. This negatively impacted the

generalisability of the trial, and made it difficult to compare the findings to the previous trial,

which included only females.

The evidence regarding the use of group-based yoga to treat AUD in comparison to any

comparison condition was ranked as ‘Unknown’ due to the fact that there was only one trial.

Individual yoga for AUD

There were no trials identified which used individual yoga as a treatment for AUD.

Group yoga and meditation for depression (compared to a non-active comparison)

There was only one trial that utilised an intervention comprising both yoga and meditation to treat

depression. The trial was an RCT involving a 12-week yoga and meditation lifestyle intervention

with five 120-minute sessions per week, compared to a routine pharmocotherapy treatment,

which the intervention group also continued. targeting depressive symptoms (N = 58).128

Participants were adults diagnosed with MDD and on routine drug treatment for at least six

months, recruited from an outpatient psychiatric unit in New Delhi. There was a significantly


53

greater decrease in depression severity within the intervention group compared to the

comparison group. There was a gender difference noted in the findings, with female participants

demonstrating significantly greater clinical improvement than male participants. While this trial

did not include a long-term follow-up assessment, it was well conducted with few methodological

flaws. A strength of the trial was its low dropout rate (7%), which indicated limited bias to the

results.

Due to there being only one trial examining yoga and meditation as a treatment for depression in

comparison to any comparison condition, the body of evidence was not ranked on direction,

consistency, generalisability, and applicability, and was therefore rated as ‘Unknown’.

Individual yoga and meditation for depression

There were no trials identified which used individual yoga and meditation as a treatment for

depression.


54

Stand-alone mindfulness treatments

For the second question, which examined the available evidence relating to mindfulness

interventions, inclusion criteria specified that the comparison group must be a conventional

psychological or pharmacological treatment for PTSD, depression, anxiety, or AUD. As such, in

order to be considered as showing a beneficial effect, mindfulness interventions were required to

be just as good as the conventional treatments, that is, demonstrate non-inferiority to

conventional treatment. For this research question, all interventions were compared to active

comparison conditions.

Group-based mindfulness for PTSD

Mindfulness Based Stress Reduction (MBSR) was used in two trials conducted in the US,

investigating its effectiveness compared to an active intervention for the treatment of PTSD.129,130

Both trials used veteran samples with formal PTSD diagnoses recruited from US Department of

Veterans Affairs (VA) medical centres.

A trial recruited veterans diagnosed with PTSD (N =116) from a VA medical centre, and were

randomly assigned to receive MBSR (n = 58) or present-centred group therapy (PCGT; n =

58).129 PCGT is a therapy which has been shown to benefit PTSD patients. It consists of nine

sessions focussed on managing current life problems related to PTSD. The results indicated that

MBSR demonstrated greater improvement than PCGT in self-reported PTSD symptom severity

at post-treatment, as well as at two-month follow-up. Although participants in the MBSR group

were more likely to show clinically significant improvement in self-reported PTSD symptom

severity at two-month follow-up, they were no more likely to have a loss of PTSD diagnosis. One

serious adverse event was reported in the PCGT group, in which a patient made a suicide

attempt. One of the trial limitations was that MBSR received longer total in-session time than the

PCGT group, which may have impacted on the treatment effects. However, the dropout rate

(15%) was relatively low.

A trial conducted in a VA primary care setting involved 62 veterans diagnosed with PTSD who

were randomly assigned to either primary care brief mindfulness training (PCBMT) for four

weeks (n = 36), or to continue with their primary care treatment as usual (PCTAU; n = 26).130

PCBMT was adapted from manualised MBSR, and included much of the MBSR content but with

a shorter session duration and fewer sessions overall. TAU in this trial typically included mental

health integrated care such as medications and brief psychotherapy delivered in primary care

settings. Participants who were randomised to PCBMT experienced similar decreases in PTSD

symptom severity compared with TAU participants at post-treatment and at 8-week follow-up,

and there were no significant differences in PTSD symptom severity between the two groups.

The results indicated a significant difference for reduction in depressive symptom severity

between the groups, with the PCBMT group showing a greater reduction in self-reported


55

depressive symptom severity. It is important to note that only 44 per cent of people in the

intervention arm completed at least three out of the four sessions. This may have caused some

attrition bias, however, intent-to-treat analysis was used to address this.

Overall, the strength of the evidence for group mindfulness interventions being effective for

treating PTSD and PTSD-related symptoms was rated as low due to the limited number of trials

identified. This rating was based on two RCTs, with one trial at risk of attrition bias due to a low

patient retention rate. Despite one trial demonstrating that the MBSR group exhibited greater

improvement in PTSD symptoms than PCGT, the MBSR group and PCGT group had similar

rates of loss of PTSD diagnosis at the end of a two-month follow-up. This demonstrates the

potential for MBSR to be as effective as PCGT, a treatment known to be effective in treating

PTSD. The other trial found no significant difference between mindfulness and conventional

treatments in PTSD symptom severity at eight-week follow-up. Finally, it was determined that this

evidence is directly applicable to the Australian context. However, given that the strength of the

evidence was low, the body of evidence for group mindfulness intervention as a treatment for

PTSD, compared to other conventional (active) treatment, was ranked as ‘Unknown’.

Individual mindfulness for PTSD

No RCTs were identified which examined mindfulness delivered to individuals, for the treatment

of PTSD.

Group-based mindfulness for depression

A total of three RCTs investigated the effectiveness of mindfulness for the treatment of

depression compared to other active interventions.131-133 All three trials used MBCT as the

mindfulness intervention for depression, and examined more severe forms of depression

including MDD and chronic depression.

One trial from the UK with a large sample size (N = 274) compared the effectiveness of MBCT (n

= 108) with cognitive psychological education (CPE; n = 110) and TAU (n = 56) in preventing

MDD relapse.133 TAU included a range of ongoing treatments that participants had started prior

to the trial, including antidepressants, psychiatric care, counselling or therapy. Participants were

in remission from MDD following at least three previous depressive episodes. MBCT had no

significant effect on risk of relapse over 12 months compared to CPE, but MBCT was associated

with a significantly lower likelihood of relapse relative to TAU, indicating that MBCT was a more

effective intervention when compared to TAU. There was no evidence, however, that MBCT was

more effective than CPE. One serious adverse reaction was reported as potentially arising from

the trial – an episode of serious suicidal ideation following discussion of different coping

responses to low mood in the CPE group. A low drop-out rate of seven per cent was observed. A

limitation of the trial includes data being analysed ‘as treated’ rather than ‘as randomised’. This

can introduce bias associated with the non-random loss of participants from the trial.


56

A three-arm, bi-centre RCT recruited 106 chronically depressed patients from Germany from two

treatment sites. This trial compared the efficacy of MBCT plus TAU (n = 36), with the Cognitive

Behavioural Analysis System of Psychotherapy (CBASP) plus TAU (n = 35), which included

continuing current medication or therapy appointments. and TAU alone (n = 35).131 The CBASP

is a manualised talking therapy that connects patients perceptually and behaviourally to the

interpersonal world. The trial results at two sites were inconsistent, showing MBCT was no more

effective than TAU in reducing depressive symptoms at one of the treatment sites, but MBCT

was significantly superior to TAU at the other treatment site. CBASP was significantly more

effective than TAU in reducing depressive symptoms in the overall sample and at both treatment

sites. Overall, the direct comparison of MBCT and CBASP in terms of changes in depression

scores at post-treatment did not reveal any statistical significance for a difference between the

two groups. Similarly for remission rates, no significant difference between MBCT and CBASP

groups was observed. Apart from suffering from a 20 per cent attrition rate, this was a well

conducted trial.

One well-designed RCT recruited 92 younger patients (mean age = 34.9 years) in remission from

MDD with residual depressive symptoms and evaluated the comparative effectiveness of MBCT

(n = 46) versus an active comparison (AC; n = 46).132 There was a 35 per cent overall drop-out

rate. The active comparison condition was based on the validated and manualised Health

Enhancement Program (HEP) and involved delivering classes in four therapeutic components

with no elements of mindfulness. This US-based trial found that over the 60-week follow-up

period, both groups experienced significant and equal reductions in depressive symptoms and

improvements in life satisfaction, and MBCT did not differ from ACC on rates of depression

relapse, symptom reduction, or life satisfaction on a statistically significant level. These results

suggested that MBCT is as effective for preventing depression relapse and reducing depressive

symptoms as the ACC, but not superior. Despite being a well conducted trial, it was limited by a

high level of drop-outs in both groups, which can introduce attrition bias.

Overall, the strength of the evidence for group mindfulness interventions to treat depression and

depression-related symptoms as effective treatments was found to be moderate to high. All three

trials had respectable sample sizes and low risk of bias, but one trial suffered from high attrition

rates. The direction of the evidence was consistent, with all three trials yielding pre-post

improvements in depression outcomes in the mindfulness group, and there were non-significant

differences between the mindfulness and comparison groups, indicating similar efficacy. The

trials were consistent in terms of the all the mindfulness treatments being manualised MBCT. A

low level of heterogeneity (i.e., population and patient recruitment methods) was detected and

therefore conferred high consistency between the three trials. The evidence suggested that

these findings are directly applicable to the Australian context. The body of evidence for group

mindfulness intervention as a treatment for depression, compared to other conventional

treatment, was ranked as ‘Promising’, and the consistent results indicated that mindfulness was


57

non-inferior to other conventional treatments for depression, specifically a more severe form of

depression such as MDD and chronic depression. While being consistently recommended in a

number of guidelines, future research is warranted to further strengthen this evidence base.

Individual mindfulness for depression

There was one trial in which mindfulness was delivered to individuals. The Dutch trial compared

the effectiveness of individual MBCT (n = 31) with cognitive behavioural therapy (CBT; n = 32)

and waitlist controls (n = 31) in patients diagnosed with type-I or type-II diabetes showing

depressive symptoms (N = 94).134 The results indicated that both MBCT and CBT significantly

decreased depression symptoms compared to the waitlist group at post-treatment. However,

direct comparisons between MBCT and CBT groups yielded no significant differences on

depression outcome. There were several limitations to this trial including a smaller sample size

limiting the statistical power. Secondly, attrition rates in both MBCT and CBT were high, with only

around 70 per cent of the randomised participants completing the treatments. In addition, the trial

sample was a group of patients diagnosed with diabetes comorbid with depression, hence the

results may not be generalisable to all types of depression.

The strength of the evidence, along with direction, consistency, generalisability, and applicability

of the evidence were not rated, as a single trial does not provide sufficient evidence for

interpretation on these aspects. The body of evidence for individually administered mindfulness

intervention as a treatment for depression, compared to other conventional treatment, was

ranked as ‘Unknown’.

Group-based mindfulness for anxiety

The largest group of trials for this section of the review, with a total of five RCTs, investigated the

effectiveness of mindfulness intervention compared to an active intervention for the treatment of

anxiety.135-139 All of the RCTs delivered interventions in group-based settings, with in-person

contact with the therapists.

A trial that was well conducted from Hong Kong randomly assigned 182 patients diagnosed with

generalised anxiety disorder (GAD) to MBCT (n = 61) or CBT-based psychoeducation (n = 61),

and TAU (n = 60), and compared the changes in anxiety levels.139 With a low drop-out rate (2%),

the trial results demonstrated there were significant decreases in anxiety levels at two and five

months compared to baseline assessment in both MBCT and psychoeducation groups, with no

significant change observed in the TAU group. However, there were no significant differences

between the MBCT and psychoeducation groups for anxiety at any time points. Some limitations

of the trial include much lower adherence for MBCT group than the psychoeducation group. The

outcome measures were based on self-reported questionnaires, and no clinician-rated

instruments or diagnostic interviews were used.


58

A trial based in Canada focussed on social anxiety disorder (SAD) recruited 137 SAD patients

and randomly assigned them to receive Mindfulness and Acceptance-based Group Therapy

(MAGT; n = 53), Cognitive-based Group Therapy (CBGT; n = 53), or waitlist (WL; n = 31) as

control.138 MAGT entails a combination of Acceptance and Commitment Therapy (ACT) and

mindfulness training. The primary outcome measure, social anxiety symptom severity, was

measured at baseline, treatment midpoint, post-treatment, and at three-month follow-up. MAGT

and CBGT were both more effective than WL at reducing symptom severity, but the trial showed

no significant reduction in social anxiety. The dropout rate was high, and the reason commonly

provided for exiting the trial was time commitment. Much of the trial data relied on self-report,

and therefore increased the risk of reporting bias. There was significant attrition (30% for MAGT

group, 40% for CBGT group), particularly affecting the follow-up data, with a total of 40 per cent

participants lost to follow-up in the MAGT group and 51 per cent in the CBGT group, impairing

the validity of the inferences drawn from the trial.

A three-arm RCT randomised a group of 108 patients from the US diagnosed with SAD into

receiving CBGT (n = 36), MBSR, (n = 36) or WL (n = 36).136 Results showed that CBGT and

MBSR both significantly reduced anxiety symptoms when compared to WL at one-year follow-up.

Both treatments yielded similar treatment efficacy, with no significant differences between CBGT

and MBSR groups. In further results looking at maintenance of reduced social anxiety symptoms,

there were no significant differences between CBGT and MBSR, suggesting similar sustained

clinical long-term outcomes at the one-year follow-up period. Drop-out from treatments was low

and did not differ significantly between the three arms (CBGT: 6%; MBSR: 8%; WL: 3%).

Limitations included that this trial used self-reported measures, which can introduce reporting

bias.

A US-based RCT included veterans (N = 105) who were suffering from anxiety disorders, who

were randomised into an adapted MBSR intervention (n = 45) or group-based CBT (n = 60).135

The adapted MBSR was shortened in duration from the manualised MBSR in order to match the

length of CBT. Reductions in anxiety symptoms between the two arms were compared. Both

groups showed large and equivalent improvements on principal disorder severity at post-

treatment and three-month follow up, with no significant differences between groups. CBT

outperformed MBSR on anxious arousal outcome at follow-up, whereas MBSR reduced worry to

a greater extent than CBT. No significant difference between the two groups was observed for

change in depression outcome, though the results favoured the MBSR group when effect sizes

were taken into account. The attrition rates were high, with only about half of patients completing

an adequate dose of treatment, with the dose defined as participation in at least 70 per cent or

10.5 hours of treatment. The sample size was reasonable, but the authors noted that it was

statistically underpowered to detect group differences of smaller effect size, and this was

exacerbated by attrition (43% drop-out in MBSR and 56% drop-out in CBT). In addition, the


59

sample is relatively diverse, consisting of patients suffering from a spectrum of anxiety disorders,

which represents a limitation to distinguishing the effects on a specific disorder.

A sample of 93 patients diagnosed with GAD from the US was randomised to either MBSR (n =

48) or Stress Management Education (SME; n = 45) to compare the effects of these

interventions on anxiety symptoms.137 The results revealed that both MBSR and SME led to

significant reductions in anxiety scores at post-treatment compared to baseline, however, there

was no significant difference between the two groups. MBSR was associated with a significantly

greater reduction in anxiety symptoms when compared to SME at post-treatment. A low drop-out

rate was observed in the mindfulness group (6% in MBSR and 24% in SME). One participant in

the MBSR group reported muscle soreness and one participant in the SME group reported sleep

disruption as adverse events.

These trials manifested a moderate to high strength of evidence for the group mindfulness

intervention, as an effective treatment for anxiety and anxiety-related symptoms. Some common

methodological limitations were identified, including a proportion of the data being lost to follow-

up, and a risk of reporting bias arising from the use of self-report measures. The direction of the

results on primary outcomes was consistent, with mindfulness interventions reducing anxiety

symptoms from baseline to follow-up, and the mindfulness interventions being as effective as the

comparison interventions. There were, however, some inconsistencies across the trials due to

the range of anxiety disorders that were targeted. Overall, these five trials were well conducted,

with good generalisability of the evidence, and direct applicability to the Australian context.

Despite some inconsistencies between trials, all trials had respectable sample sizes, with results

accordant to each other. With the methodological limitations in mind, the body of evidence for

group mindfulness intervention as a treatment for anxiety, compared to other conventional

treatment, was ranked as ‘Promising’, as the evidence is suggestive of beneficial effect.

Individual mindfulness for anxiety

No RCTs were identified which examined mindfulness delivered to individuals for the treatment

of anxiety.

Group-based mindfulness (mindfulness group therapy) for combined depression and

anxiety

A heterogeneous sample consisting of 215 individuals suffering from depression, anxiety, stress,

and adjustment disorders were recruited from 16 primary care clinics in South Sweden to explore

the efficacy of MBCT (n = 110) versus TAU (n = 105) (the majority of participants received

individual CBT for TAU) on depression and anxiety symptoms.140 The trial suffered from a 21 per

cent drop-out rate. Both MBCT and TAU groups exhibited significant reductions in depression

and anxiety symptom severity, however, there were no significant group differences post-

treatment. The trial sample was a mix of patients diagnosed with depression, anxiety, stress, and


60

adjustment disorders, and therefore it was difficult to clearly distinguish the effect of the

mindfulness practices on one targeted disorder.

Given there was one single trial which examined group-based mindfulness as a treatment for

combined anxious and depressed patients, the strength of the evidence, as well as the direction,

consistency, generalisability and applicability of the evidence were not rated. The body of

evidence for mindfulness intervention for treating heterogeneous depression and anxiety,

compared to other conventional treatment, was ranked as ‘Unknown’.

Individual mindfulness for combined depression and anxiety


of combined depression and anxiety.

Group-based mindfulness for AUD

Three RCTs, all of which were US-based, investigated the effectiveness of a group-based

mindfulness intervention compared to an active intervention for the treatment of AUD.141-143

Garland and colleagues from the US141,142 adapted a mindfulness intervention for depression,

MBCT, to specifically target addiction, called Mindfulness-Oriented Recovery Enhancement

(MORE). Both trials recruited patients from a modified therapeutic community in an urban area in

the US. In the 2010 RCT consisting of 53 alcohol-dependent adults, the pilot study compared the

effectiveness of MORE (n = 27) to an Alcohol Support Group (ASG; n = 26) on psychosocial

factors related to alcohol dependence and stress.141 The study had approximately 31 per cent of

participants drop out. While MORE led to significant decreases in thought suppression, ASG led

to increased thought suppression. Comparing the two groups, MORE significantly reduced stress

and thought suppression, increased physiological recovery from alcohol cues, and modulated

alcohol attentional bias when compared to the ASG group. Furthermore, the post-treatment

results indicated both MORE and ASG led to significant reductions in perceived stress over time.

However, the findings should be interpreted with caution, as the study suffered from several

limitations including a small sample size which limited the statistical power and generalisability.

Another notable limitation was that self-report measures were administered through face-to-face

interviews which may have led to social desirability bias in these self-reported outcomes.

In a 2016 RCT142, Garland et al. conducted a trial consisting of a larger sample size of 180 men

with co-occurring substance use and psychiatric disorders, comparing the effectiveness of

MORE (n = 64) to CBT (n = 64) and TAU (n = 52) on alcohol craving, as well as symptom

severity of PTSD, anxiety and depression. Of this sample, 45 per cent had an alcohol

dependence diagnosis. There was an approximately 29 per cent drop-out rate. In the MORE

group, there was a significant decrease in alcohol craving at post-treatment. There was also a

significant reduction in PTSD, depression, and anxiety symptom severity in the MORE group.

Significant differences were not observed among the CBT group, with only depression symptom


61

severity showing moderate reduction at post-treatment. Comparing MORE to CBT, the MORE

group showed better improvement in alcohol craving, as well as a significantly greater reduction

in PTSD symptom severity. However, the trial sample included patients with different types of

substance use disorders including alcohol, opioids, cannabis and hallucinogens. Therefore, the

effects on AUD-only patients cannot be clearly distinguished. The male sample population may

limit the generalisability of the findings to women.

A parallel RCT in the US investigated the effectiveness of mindfulness-based relapse prevention

for alcohol (MBRP-A) compared to TAU on self-reported alcohol problems in 123 alcohol

dependent adults recruited from eight local addiction treatment centres.143 The participants were

randomised to either receive MBRP-A (n = 64), or to continue their TAU (n = 59), which typically

included motivational enhancement, relapse prevention, and 12-step facilitation strategies.

Twenty-eight per cent of the participants from the MBRP-A group failed to complete more than

four sessions. At the end of treatment, the intervention group reported a mean score of 5.8 for

change in alcohol problems since starting the trial on a self-report measure, indicating substantial

improvements in alcohol problems. This outcome was not assessed in the comparison group,

however, and no statistical comparison was made between the two groups, which represents a

major limitation of the trial. In addition, the primary outcome measure used in this trial had not

been validated, and the outcomes were not based on any standard clinical assessments.

Overall, the strength of the evidence for group mindfulness interventions to effectively treat AUD

and AUD-related symptoms was found to be low. This rating was based on three trials which

were all susceptible to a high level of risk for bias. In the two trials by Garland et al., which used

MORE to treat alcohol-use symptoms, the 2010141 trial used a small sample of alcohol-

dependent patients hence limiting the statistical power; the 2016142 trial was well conducted and

had a large sample size, however, the trial used patients suffering from a range of substance-use

disorders with 45 per cent diagnosed with alcohol dependence, greatly limiting the

generalisability of the results to AUD-only patients. The third trial, by Zgierska et al.,143 which

used MBRP-A as a mindfulness intervention, lacked statistical comparison to the comparison

group. In addition, the primary outcome measure was not validated. The findings from these

three trials are equivocal due to high risk of bias and methodological limitations, and therefore

the body of evidence for mindfulness intervention as a treatment for AUD, compared to other

conventional treatment, was ranked as ‘Unknown’.

Individual mindfulness for AUD


of AUD.


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Adjunct meditation, yoga and mindfulness treatments

A group of literature was identified, which examined meditation, yoga, and mindfulness as an

adjunct treatment to established psychological or pharmacological treatments for PTSD,

depression, anxiety, and AUD. This part of the review aims to look at whether adjunct meditation,

yoga, or mindfulness therapies confer additional benefits in synergy with conventional

treatments. That is, these trials were required to demonstrate a greater benefit deriving from the

addition of meditation, yoga, or mindfulness to other psychological or pharmacological treatment.

These results are illustrated below.

Adjunct meditation

Adjunct meditation for PTSD

There were no trials identified which used adjunct group-based or individual meditation for the

treatment of PTSD.

Adjunct meditation for depression


treatment of depression.

Adjunct meditation for anxiety


treatment of anxiety.

Adjunct meditation for AUD


treatment of AUD.

Adjunct yoga

Adjunct group-based yoga for PTSD (compared to active comparison)

A US trial examined the effectiveness of trauma-informed group yoga compared to supportive

women’s health education, both adjunct to psychopharmacologic treatments for a group of

women with chronic, treatment-resistant PTSD.144 Trauma-informed group yoga is a manualised

ten-week program incorporating the central element of Hatha yoga that emphasises curiosity

about bodily sensation. The women’s health education intervention aimed to increase women’s

self-efficacy to seek medical services and improve self-care. A low drop-out rate was observed

(6%). Patients (N = 64) were randomly assigned to either trauma-informed yoga (n = 32) or

supportive women’s health education (n = 32); outcome measurements were taken pre, mid, and

post-treatment. For the primary outcome, PTSD symptom scores, both groups exhibited


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significant decreases on the clinician-rated PTSD symptoms, with a statistically significantly

greater magnitude of reduction in symptoms observed in the yoga group compared to the

comparison group. Both groups also demonstrated significant decreases on self-reported PTSD

symptoms, but there was no significant difference between the groups in reductions. During the

first half of the treatment, these improvements were maintained throughout treatment in the yoga

group, but not in the comparison group. The trial sample consisted only of treatment-resistant

adult women with chronic PTSD secondary to interpersonal assaults that started in childhood,

limiting the generalisability of findings.

Since there was only a single RCT examining group-based yoga as an adjunct treatment for

PTSD, the strength of the evidence, as well as the direction, consistency, generalisability, and

applicability of the evidence were not rated. The body of evidence for group-based yoga

intervention as an adjunct to other conventional treatment for PTSD was ranked as ‘Unknown’.

Adjunct individual yoga for PTSD

There were no trials identified which used adjunct individual yoga for the treatment of PTSD.

Adjunct group-based yoga for depression (compared to active comparison)

Three trials compared group-based yoga as an adjunct treatment for depression with active

controls.145-147

A trial from the US compared the effectiveness of Hatha yoga to a ‘Healthy Living Workshop’

(HLW) intervention as adjunct treatments to antidepressant medication for treating MDD.147 Post-

treatment, no statistically significant difference in depression symptom severity was observed

between the yoga group (n = 63) and the comparison group (n = 59). When baseline depression

severity was controlled for, there was no significant difference in depression symptoms between

the two groups post-treatment. Yoga participants showed significantly fewer depression

symptoms than HLW participants at both three-month and six-month follow-up, suggesting that

the benefits of yoga may accumulate over time. The trial had a low drop-out rate (8%). A

limitation of this trial was that the sample was predominantly females which may limit

generalisability to other populations.

One pilot RCT (N = 25) conducted in the US evaluated the efficacy of Sudarshan Kriya Yoga

(SKY) as an adjunct intervention for patients diagnosed with MDD who were taking anti-

depressants.146 The SKY intervention consisted of two phases of a manualised group program,

featuring a breathing-based meditative technique. Patients with MDD and more than eight weeks

of antidepressant treatment, were randomised to SKY (n = 13) or a waitlist control arm (n = 12)

for eight weeks. A 24 per cent overall drop-out rate was observed. Results indicated that the

SKY group showed a greater improvement in depression symptoms, compared to the waitlist

control from baseline to two-months follow-up. The results from this pilot study suggested that an


64

adjunct SKY-based intervention may be promising for treating patients with MDD with the caveat

that the very small sample size considerably limits the statistical power of the study.

A German RCT (N = 53) compared the effectiveness of Hatha yoga as an adjunct treatment to

atypical antipsychotic drugs with antidepressant properties (n = 22) with a comparison group (n =

31) receiving antipsychotic drugs only for treating MDD.145 A statistically significant reduction in

depressive symptoms at post-treatment was observed in both groups over time, but there was no

significant group difference. The drop-out rate was not specified. The trial was limited by a small

sample size and an unequal number of participants in the intervention and comparison arms.

The sample was also predominantly male, limiting the generalisability of findings.

Overall, there is low evidence for adjunct group-based yoga to treat depression and depression-

related symptoms, when compared with an active comparison. It should be noted that within this

group of studies, active comparison treatments were limited to pharmacotherapy as no trials

were identified that compared adjunct group-based yoga to psychological therapy. The three

RCTs each suffered from some methodological limitations, for example, small sample sizes145,146

and poor randomisation processes which resulted in unequal numbers of participants in the

intervention and comparison arms.145 The direction of the results of the three trials was shown to

be positive, demonstrating that yoga interventions exerted additional beneficial effects as an

adjunct treatment for depression when compared to the comparison groups. Some

inconsistencies existed in sample populations, comparison interventions, sample size, and

outcome assessments, suggesting that the results are somewhat unlikely to be replicable.

Nevertheless, these variations in demographic representation amount to good generalisability for

the trial findings, as the three trials recruited different demographic groups comprising both

males and females of varying age groups. The populations examined in the evidence are overall

representative and comparable to the target population. The evidence was considered to be

directly applicable to the Australian context. While the results were shown to be pointing towards

a positive direction, the evidence for adjunct group-based yoga for depression was ranked as

‘Unknown’, due to the high risk of bias across the trials which impeded the evidence from being

ranked as promising. Nonetheless, there is an apparent positive effect of yoga intervention as an

adjunct to pharmacological treatment for depression when compared to an active comparison

group. Therefore further research is necessary to explore this association, and to examine the

impact of adding group-based yoga as an adjunct to psychological therapy.

Adjunct group-based yoga for depression (compared to non-active comparison)

An RCT recruited 56 depressed patients from a district hospital in Vietnam to examine the

effectiveness of a yoga intervention as an adjunct intervention to psychoeducation, compared to

TAU 148 Thirty-four patients were randomised to receive the adjunct yoga intervention and 22

patients were randomised to continue their treatment as usual. The intervention group had a

significantly greater reduction in depression symptoms on average than the comparison group at


65

post-treatment. Almost half of the patients in the intervention group no longer met criteria for a

diagnosis of depression, whereas no one from the comparison group lost their depression

diagnosis. However, it should be emphasised that there were some weaknesses in the

randomisation procedure that resulted in unequal numbers of participants in the intervention arm

and comparison arm, which can seriously confound the analyses. In addition, a self-report

measure was used as the single outcome measure for depression, potentially reducing the

reliability of the findings. This trial had a 20 per cent drop-out rate. A major design shortcoming

was that those in the intervention group received both yoga and psychoeducation, while those in

the comparison group received neither. This hampered our ability in interpreting the results as it

is difficult to know what to attribute the improvements to – the yoga or the psychoeducation

intervention. Another significant limitation was the fact that the study did not state what the TAU

condition consisted of, thus limiting the level of inference that could be made regarding the

comparison between the intervention and comparison conditions.

As there was only a single RCT which compared group-based yoga as an adjunct treatment for

depression with a non-active comparison, the strength of the evidence, as well as the direction,

consistency, generalisability, and applicability of the evidence were not rated. The body of

evidence for group-based yoga intervention as an adjunct to other conventional treatment for

depression, compared to a non-active comparison, was ranked as ‘Unknown’.

Adjunct individual yoga for depression

There were no trials identified which used adjunct individual yoga for the treatment of

depression.

Adjunct group-based yoga for anxiety

There were no trials identified which used adjunct group-based yoga for the treatment of anxiety.

Adjunct individual yoga for anxiety

There were no trials identified which used adjunct individual yoga for the treatment of anxiety.

Adjunct group-based yoga for AUD (compared to an active comparison)

A Swedish pilot study examined the adjunct use of 10 weeks of yoga with TAU compared to TAU

alone for changes in alcohol consumption, affective symptoms, quality of life, and stress.149 TAU

consisted of individual counselling sessions with a CBT focus, typically one hour per week led by

a medical doctor or psychologist, with the prescription of medication for alcohol dependence as

required. Assessments were taken at baseline and six-month follow-up; there was no

assessment at post-treatment, representing a major design flaw. Eighteen participants were

randomised to the two groups, but due to drop-out the final analyses included 14 participants,

representing a 22 per cent overall drop-out rate. Both groups improved from baseline to six-

month follow-up on all measures, however, there were no significant differences between the


66

groups. This suggested that adding yoga to TAU was no more effective in reducing alcohol

consumption, alcohol dependence, and stress, and improving mood and quality of life, than TAU

alone. The study suffered from limited statistical power due to a very small sample size, no post-

treatment assessment, and a high drop-out rate.

Given that there was only one single poor quality pilot study looking at adjunct group-based yoga

as a treatment for AUD, the strength of the evidence was found to be low. The direction,

consistency, generalisability, and applicability of the evidence were not rated due to the lack of

an evidence base. The evidence for group-based yoga as an adjunct to other conventional

treatment for AUD was ranked as ‘Unknown’.

Adjunct individual yoga for AUD

There were no trials identified which used adjunct individual yoga for the treatment of AUD.

Adjunct mindfulness

Adjunct group-based mindfulness for PTSD (compared to an active comparison)

A single RCT compared the effectiveness of MBCT with socio-therapeutic events (STE) as add-

on treatment to selective serotonin reuptake inhibitor (SSRI) medication in a group of veterans

diagnosed with PTSD.150 Socio-therapeutic events included participating in a range of social

activities such as talking about daily life experiences, playing board games, and undertaking

short trips. Male outpatient military veterans (N = 48) diagnosed with PTSD were recruited from a

psychiatric hospital in Iran, with participants randomised to receive yoga plus medication

intervention (n = 22) or medication and STE (n = 31). Assessments were taken at pre and post-

treatment. No participant from either arm dropped out of the trial. The trial results indicated that

overall, PTSD symptom severity was lower at post-treatment compared to baseline in both

conditions, with the MBCT group exhibiting greater mean significant reductions from pre to post-

treatment than the comparison group. The results suggest that MBCT as an adjunct to standard

SSRI medication is an effective intervention for reducing symptoms of PTSD among veterans.

There were several limitations of the trial, including a relatively small sample size which limited

the statistical power. The trial participants were all male, reducing the generalisability of the

results. In addition, all outcome measures relied on self-report entirely. Using clinician ratings

may have made the data more robust. The trial did not collect any follow-up data, and therefore

the long-term effectiveness of MBCT as an add-on treatment for PTSD cannot be determined.

Due to there being only a single trial examining the effectiveness of adjunct group-based

mindfulness to treat PTSD, the strength of the evidence was found to be low. The direction,

consistency, generalisability, and applicability of the evidence were not rated due to the lack of

the evidence base. The evidence for group-based mindfulness an adjunct to other conventional

treatment for PTSD was ranked as ‘Unknown’.


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Adjunct individual mindfulness for PTSD

There were no trials identified which used adjunct individual mindfulness for the treatment of

PTSD.

Adjunct group-based mindfulness for depression (compared to an active comparison)

A total of three RCTs investigated the effectiveness of adjunct mindfulness interventions,

delivered in face-to-face group settings, for the treatment of depression.151-153

A large-scale well-designed RCT from the UK (N = 424) compared MBCT with support to taper

or discontinue anti-depressant treatment (MBCT-TS; n = 212) with maintenance anti-depressant

medications (mADM; n = 212), in a group of patients with recurrent MDD.151 There was an

overall 13 per cent drop-out rate, with the majority of the drop-out occurring in the mADM-only

group (23.6% drop-out rate). At 24-month follow-up, the time to relapse or recurrence of

depression did not differ significantly between the two groups. There was no significant

difference in either depression-free days or in residual depressive symptoms between the two

groups. The trial found no evidence to suggest that MBCT-TS was more effective than mADM

alone in preventing depressive relapse/recurrence among at-risk individuals. Both treatments

appeared to confer protective effects against depression relapse/recurrence. This was a well

conducted trial overall with no obvious limitations, strengthened by a large sample size providing

ample statistical power. It should be noted that ten serious adverse events were reported, four of

which resulted in death. It was concluded that these adverse events were not attributable to the

intervention or the trial.

An RCT conducted in the Netherlands with a relatively small sample size (N = 68) examined the

effectiveness of adding MBCT to the treatment routine of a group of recurrently depressed

patients in remission who were using mADM.153 There was A 15 per cent drop-out rate in the

MBCT plus mADM group, and a 40 per cent non-adherence rate in the mADM-only group. This

trial yielded similar results to the UK trial,151 with no significant differences in relapse/recurrence

rates between the two groups within the 15-month follow-up period. There was no difference in

time to relapse/recurrence between the two conditions. Patients maintained mild levels of

depression over the 15-month follow-up period, and the course of depression did not differ

significantly between the conditions. Therefore, adding MBCT to mADM did not further reduce

the risk of relapse/recurrence or residual depressive symptoms. However, the results were

confounded by the increasing availability of MBCT in the Netherlands – almost a quarter of the

individuals who were randomised into the comparison condition decided to participate in an

MBCT course elsewhere, outside of the trial.

Based on previous work, one RCT was conducted in the US (N = 173) which compared the

effectiveness of MBCT (n = 87) with a Health-Enhancement Program (HEP) (n = 86) as an

adjunct to pharmacotherapy in a group of patients with treatment-resistant MDD.152 HEP


68

included many therapeutic components, such as aerobic exercise, music therapy, functional

movement, and dietary education. There was a drop-out rate of 16.3 per cent in HEP, and 12.7

per cent in the MBCT group. Relative to the HEP condition, the results yielded supporting

evidence for MBCT as an effective intervention in reducing depressive symptom severity,

showing a greater mean per cent reduction at 12-month follow-up, and a significantly higher rate

of treatment responders than the HEP group. However, when compared to HEP, although

numerically superior for MBCT than for HEP, the rate of remission did not differ significantly

between the two groups over the 12-month follow-up period. Limitations of the trial included that

the two interventions were delivered by two different sets of instructors, introducing a potential

source of bias.

The strength of the evidence for mindfulness group-based intervention as an adjunct treatment

for depression was found to be moderate. All trials in this category examined mindfulness as an

adjunct to pharmacotherapy, with the comparison groups receiving pharmacotherapy

interventions only. All trials manifested good consistency. However, the trials revealed

differences in direction of the results, with one trial concluding that the MBCT group showed

greater improvement than the comparison group, while the other two trials showed non-

significant results between groups. These mixed results may indicate that adding a mindfulness

intervention to pharmacotherapy confers no additional benefit. All three trials used samples with

a higher proportion of female participants, limiting the generalisability. The mindfulness

interventions were considered to be highly applicable to the Australian context. The evidence for

mindfulness as an adjunct to other conventional treatment for depression was ranked as

‘Unknown’. Despite the trials in this category being generally of good quality, this rating was

affected by the different direction of the results on depression outcomes.

Adjunct individual mindfulness for depression

There were no trials identified which used adjunct individual mindfulness for the treatment of

depression.

Adjunct group-based mindfulness for anxiety

There were no trials identified which used group-based mindfulness for the treatment of anxiety.

Adjunct individual mindfulness for anxiety

There were no trials identified which used individual mindfulness for the treatment of anxiety.

Adjunct group-based mindfulness for AUD

There were no trials identified which used group-based mindfulness for the treatment of AUD.

Adjunct individual mindfulness for AUD

There were no trials identified which used individual mindfulness for the treatment of AUD.


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Discussion

The aim of this review was to assess the evidence related to the efficacy of meditation, yoga,

and mindfulness interventions to treat PTSD, depression, anxiety, and AUD in adults. Although

there is substantial overlap in the components, effects, and mechanisms of these three types of

interventions, distinctions have been drawn in this review where possible. The interventions

examined in the current review were divided into two main categories, stand-alone and adjunct

treatments, and these treatments were further separated into two modes of treatment delivery,

individual or group-based. For Questions 1 and 3, these were further divided based on the type

of comparison condition (active or non-active comparison condition).

The results of the REA showed that three stand-alone group interventions – group-based yoga to

treat depression, group-based mindfulness to treat depression, and group-based mindfulness to

treat anxiety – were ranked as ‘Promising’, while the remaining categories were ranked as

‘Unknown’. However, the ‘Unknown’ categories contained findings that are potentially relevant to

future research in these areas, which we discuss in the section below.

Despite limiting the included study designs to RCTs, which are the most rigorous study design,

the majority of the evidence was considered insufficient to support the use of these meditation,

yoga and mindfulness interventions to treat PTSD, depression, anxiety, or AUD. The key

limitations of the trials included in this review were small sample sizes, inconsistent results, and

high attrition rates, which all impact on the quality of the trials and the certainty that can be

placed on the trial findings.

In considering the strength and consistency of the evidence, it is important to note the varying

inclusion criteria that existed for each section of the review. The first question regarding the role

of meditational practices including meditation, mantram, and yoga in mental health treatments for

PTSD, depression, anxiety, and AUD included RCTs that compared these interventions to any

comparison (pharmacotherapy, therapy, control, or waitlist conditions). Results separated RCTs

comparing meditation and yoga to active comparison conditions from those comparing to non-

active comparison conditions. In order to be considered a significant finding of beneficial effect,

those receiving the meditation or yoga-based interventions comparing to non-active comparison

conditions were required to show greater improvement in primary outcomes than those in the

comparison condition, while for those comparing to an active condition were required to show

non-inferiority to the comparison treatment. For the second question, however, which examined

the available evidence relating to mindfulness interventions, inclusion criteria specified that the

comparison group be a conventional psychological or pharmacological treatment for PTSD,

depression, anxiety, or AUD. As such, in order to be considered as showing a beneficial effect,

mindfulness interventions were required to be just as good as the conventional treatments, that


70

is, demonstrate non-inferiority to conventional treatment. The third question investigated the use

of both meditational and mindfulness interventions as adjunct to conventional psychological or

pharmacological treatment of PTSD, depression, anxiety, and AUD. In order to be considered as

showing a beneficial effect, those receiving the adjunct meditational and mindfulness

interventions were required to have significantly greater improvement than the comparison group

on the outcome of interest. The comparison groups included those with active and non-active

comparison conditions, and these were separated in the reporting of results. They were required

to demonstrate a benefit to adding meditation, yoga or mindfulness to other psychological or

pharmacological treatment.

Stand-alone meditation and yoga treatments

Group-based yoga was ranked as ‘Promising’ in the treatment of depression, as it was found to

be more effective than comparison groups that consisted primarily of waitlist control conditions.

As only one trial within this group included a long-term follow-up, the finding of group-based yoga

being a promising treatment for depression can only be applied to short-term outcomes. Further

research with long-term follow-up assessment is required to ascertain if the benefits of yoga on

depressive symptoms are sustained over time. Additional research with larger sample sizes and

more representative samples that include a more balanced ratio of males and females from the

general population could provide more substantial evidence that could promote group-based

yoga to be ranked ‘Supported’ in the treatment of depression.

There are several mechanisms cited in the literature that support the use of group-based yoga as

a promising intervention for depression. While it is beyond the scope of this review to draw

conclusions on which mechanisms are involved in this finding, there are a number of potential

mechanisms that can be considered. The literature suggests that self-regulatory aspects of yoga

can target specific cognitive symptoms such as rumination and dysfunctional beliefs.85

Decentring, previously mentioned in the introduction as a process by which one’s thoughts and

feelings are viewed as being objective events rather than identified with oneself, is promoted in

yoga and meditational practices. This process allows individuals to observe negative thoughts in

an objective manner and minimise ruminative thoughts.68 Evidence from the current review

supports this potential mechanism, as one of the included trials identified rumination as the only

outcome with a significant reduction in the yoga group compared to the comparison group

immediately post-intervention, with a sustained reduction in rumination and overall depressive

symptoms at one-year follow-up.118,119

An association between depression and autonomic dysfunction also suggests a potential

mechanism for yoga to improve depressive symptoms. Yoga practice is associated with

increased parasympathetic activity and reduction in overactive sympathetic nervous system

activity.42 The breathing techniques practised in yoga result in adjustment of the imbalance in


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the autonomic nervous system and particularly increased parasympathetic activity, thus resulting

in a state of relaxation. 32,116

Reductions in cortisol levels are associated with the practice of yoga, and also with reductions in

depressive symptoms.117 Within this context, it is somewhat difficult to separate the benefits of

yoga with that of exercise more broadly. Exercise is known to improve depressive symptoms,80

reportedly though behavioural activation, which involves the process of altering lifestyle choices

to disrupt depressive routines.120 The exercise component of yoga may thus utilise similar

mechanisms to relieve depressive symptoms. One of the reviewed papers examined group-

based yoga amongst pregnant women with depression and anxiety and found that participants in

both the yoga and comparison condition all reported improved depressive symptoms, with no

significant difference between groups. Participants in both groups engaged in physical activity

levels that were higher than that of the general population of pregnant women.123 This may have

contributed to the reduction in depressive symptoms such that the effects of yoga could not be

distinguished.

The evidence for group-based yoga as a treatment for PTSD was ranked as ‘Unknown,’ but the

findings were suggestive of the potential benefits of yoga on re-experiencing, avoidance, and

hyperarousal symptoms. The wider literature has identified the role of body awareness as a

mechanism by which yoga can facilitate an enhanced awareness of physiological states in order

to more effectively regulate arousal.11,32 The modulation of physiological arousal is particularly

important for those suffering from PTSD, and findings from this investigation suggest that

breathing practices can reduce hyperarousal symptoms, while increased awareness can reduce

re-experiencing symptoms.112 Yoga and breathing exercises have been suggested as more

suitable for individuals with PTSD than mindfulness and other types of meditation, as it may be

difficult for those with high physiological arousal to sit silently.11 Due to the methodological

limitations of small sample sizes and high attrition rates, however, the evidence considered in

this current review was not considered supportive of the use of group-based yoga to treat PTSD.

The comparison groups in these trials suggest other factors may contribute to the efficacy of

yoga as a treatment. Despite being waitlist, TAU, or assessment-only conditions, most of the

comparison groups engaged in some self-monitoring and social interaction as part of

assessments. This may have contributed to reduction of symptoms in comparison groups, thus

leading to lack of significant differences between the comparison and yoga groups.113 Individual

motivation is also suggested to play a role in the efficacy of yoga interventions. One of the trials

within this review found that while there was no significantly greater reduction in symptoms in an

initial yoga group compared to comparison, there was significant symptom reduction in self-

selected participants in the waitlist group who chose to participate in the yoga intervention.

Future trials taking these factors into consideration, as well as implementing more rigorous


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methodologies, may provide more information about the potential of group-based yoga as a

treatment for PTSD.

In the treatment of PTSD, mantram meditation was also found to have findings of particular

interest. Only one trial examined group-based mantram meditation and one examined individual

mantram meditation, and therefore the evidence could not be ranked. However, both trials were

well conducted and indicated support of the mantram repetition program.107,109 Short-term

benefits of this intervention were supported by both trials, and it was found to be effective in both

group-based and individually-delivered formats. Mantram meditation in particular is known to

increase present-centred awareness and promote a focus on the present rather than past

trauma-related memories, which in turn can reduce intrusive and hyperarousal symptoms.35

These findings may warrant future research examining mantram repetition programs as a

treatment for PTSD.

As the evidence for group-based yoga for treatment of depression was found to be ‘Promising’, it

was somewhat surprising that the same was not found for evidence regarding group-based yoga

to treat combined samples of depression and anxiety. This evidence was ranked as ‘Unknown’,

primarily due to methodological limitations such as sample sizes, unclear randomisation

methods, lack of blinded assessment, and high attrition rates. It was also not possible to

determine if the intervention was only effective for treating depression, anxiety, or both, given

that separate analyses were not conducted.

The evidence for individual yoga for anxiety and group-based yoga for AUD was ranked as

‘Unknown’ due to having only one trial within each group. Insufficient evidence within both of

these categories warrants the support of future research examining yoga as an intervention for

these disorders. For anxiety in particular, the literature suggests benefits of yoga intervention that

are similar to those of PTSD, with body awareness reducing physiological arousal, which is

characteristic of anxiety.32

Stand-alone mindfulness treatments

Two manualised treatments, MBSR and MBCT, emerged as the most promising mindfulness

interventions in this review. MBCT appeared to be more widely used in trials targeting

depression symptoms, and MBSR is more commonly used to treat anxiety.

The evidence for mindfulness as a treatment for depression in the current review was ranked as

‘Promising’, indicating that MBCT is a treatment that is as effective as other conventional

treatments for treating depression. MBCT may be particularly effective as a treatment for

depression relapse prevention in those suffering from recurrent depression, and this effect was

more pronounced in those who exhibit residual depressive symptoms.154 MBCT has been

consistently recommended in a number of guidelines for treating depression, especially for


73

recurrent depression. However, these guidelines commonly report the efficacy of mindfulness in

comparison to TAU or non-active comparison conditions. As such, it is not possible to compare

these guidelines with findings from the current review, which compared mindfulness to active

comparison treatments. As this review only focussed on the strength of the evidence regarding

whether mindfulness is of equal effectiveness to other conventional (active) treatments for

depression, further trials are warranted in exploring this specific aspect.

MBCT is thought to exert such benefits via a range of mechanisms. Reductions in negative self-

referential processing and improvements in attention regulation are associated with mindfulness

meditation, which may lead to gradual, but sustained reductions in depression symptoms.132

Learning self-compassion was also found to have a mediating effect in the association between

MBCT participation and depression over a 15-month follow-up.155 Self-compassion is associated

with more adaptive coping responses, greater engagement in proactive problem-solving, and

decreases in negative affect.156

Evidence for mindfulness as a treatment for anxiety was also considered as ‘Promising’. The

mechanism of actions in ameliorating anxiety symptoms seems to differ between MBSR and

CBT. Researchers theorised that MBSR may be effective at improving cognitive symptoms of

anxiety, such as ruminative worry processes, however, when compared to CBT, MBSR may be

less effective in improving the physical symptoms of anxiety, which includes perceived arousal

symptoms.135 MBSR has also been proposed to reduce worry via greater awareness of thoughts

and physiological states and encouraging non-reactivity to such states.157

Several neurobiological mechanisms have also been suggested for the utility of MBSR for

anxiety disorders. Changes in the dorsomedial pre-frontal cortex were observed in a trial of

social anxiety; this region of the brain is thought to be involved in creating a sense of the self,

and associated with significant reductions in social anxiety.158 A separate trial of MBSR detected

changes in the ventrolateral pre-frontal regions as well as in amygdala-prefrontal connectivity,

which is involved in emotion regulation and fear extinction.159

While there is evidence suggesting that mindfulness-based treatments work via these

hypothesised mechanisms, this area of research did not achieve a ‘Supported’ ranking, therefore

no direct recommendation can be made for mindfulness being the first-line treatment for

depression or anxiety. There is also a lack of rigour in the methodologies of trials examining the

mechanism of action, which precludes any definitive conclusions being made.

Two trials examined the effectiveness of mindfulness for the treatment of PTSD, and both trials

utilised MBSR. Although MBSR was associated with a decrease in PTSD symptomology over

time, the strength of the evidence base was low due to a limited number of studies. In addition,

some researchers have suggested that mindfulness-based practices may destabilise patients

who are susceptible to flashbacks and rumination, or prone to trauma-triggered memories.35


74

Future trials are needed to ascertain whether mindfulness-based treatments are appropriate for

PTSD and to understand the impact of patient symptomatology and characteristics.

The trials included in this review, provide supporting evidence for mindfulness practices leading

to post-treatment improvement in substance use behaviour, such as decreasing alcohol craving,

thought suppression, increasing physiological recovery from alcohol cues, and modulating

alcohol attentional bias.141 However, the evidence that informed these findings was of poor

quality, meaning that we can have limited confidence in these findings at the present time. This

aspect is worth further investigation, as there is preliminary evidence suggesting efficacy of

mindfulness practices in the treatment of AUD.

Adjunct meditation, yoga and mindfulness treatments

All of the evidence for the effectiveness of yoga and mindfulness as adjunct treatments for

PTSD, anxiety, depression, and AUD was rated as ‘Unknown’. This was somewhat surprising

given that both mindfulness and yoga were ranked as ‘Promising’ for certain populations when

delivered as stand-alone treatments. Given that CBT has been found to be more effective when

augmented with other standard treatments such as medication,152 it may be expected that there

would be similar results when yoga and mindfulness interventions were delivered as adjunct

treatments to standard treatment, particularly for the treatment of depression and anxiety, for

which promising evidence was found in stand-alone treatments. Four trials examined the efficacy

of adjunct group-based yoga to treat depression with a positive direction indicating that yoga

interventions demonstrated additional benefits as adjunct treatments when compared to

comparison groups. However, due to high risk of bias resulting from methodological limitations of

the trials reviewed, the evidence base for adjunct group-based yoga as a treatment for

depression was rated as ‘Unknown’.

The evidence examining adjunct group-based mindfulness for depression was also ranked as

‘Unknown’. As previously discussed, mindfulness practices work through teaching participants to

self-regulate attention to the present moment in a non-judgmental, accepting way.16 It should be

highlighted that all trials in this category examined mindfulness as an adjunct to

pharmacotherapy, with the comparison groups receiving pharmacotherapy interventions only.

This was also the case for most of the trials investigating yoga as an adjunct treatment for

depression. This suggests that the influence of yoga may have been too small to detect

alongside antidepressant medication, particularly with the low frequency of yoga sessions.145

However, all the trials examining yoga as a treatment, as well as those pertaining to adjunct

mindfulness interventions, suggest that these interventions are associated with minimal adverse

effects. Adverse effects reported in the trials were deemed unrelated to the intervention or the

trial. While psychiatric medications can be powerful and potent, they can have undesirable side

effects, so it may be beneficial to further investigate the potential of MBSR/MBCT for tapering or


75

ceasing the use of pharmacotherapy. One trial found evidence to support MBCT in tapering or

discontinuing antidepressant treatment (MBCT-TS) as an alternative to maintenance

antidepressants for prevention of depressive relapse, also showing comparable cost-

effectiveness.151 Given that the findings of these trials examining meditational and mindfulness

interventions as adjunct treatments are highly dependent on the type of intervention that they are

delivered alongside, further research is required before determining whether this format of

delivery is more effective than stand-alone interventions. Research comparing these

interventions with various types of standard treatments, including pharmacotherapy and

psychological therapy, is warranted in order to make larger inferences.

The evidence for adjunct treatment approaches for PTSD were all ranked as ‘Unknown’,

however, this was due to a paucity of research, with only one trial in each of the groups. While

one trial was found to have greater benefits for PTSD symptomatology in those participating in

group-based yoga as an adjunct to pharmacotherapy,144 there was insufficient evidence for this

treatment to be considered ‘Promising’. The literature provides some guidance regarding the role

of meditational and yoga practices in the treatment of PTSD, suggesting that yoga might reduce

aspects of PTSD symptoms such as those linked to stress and hyperarousal, so as to prepare

individuals for more intensive trauma-focussed therapies.10 Further research is warranted in

order to better understand the benefits of participating in yoga or meditation prior to

psychological therapy.

Limitations

The findings from the REA should be considered alongside its limitations. It is important to note

that several caveats were associated with the methodology in order to make the review ‘rapid’. A

stringent criteria for study inclusion was applied: publications that were not in English were

omitted; reference lists of the included papers were not hand-searched to retrieve any additional

relevant studies. Although we did evaluate the evidence in terms of its strength, consistency, and

generalisability, these evaluations were not as exhaustive as in a systematic review

methodology. A meta-analytic methodology was not applied to synthesise these results

quantitatively. Furthermore, the studies were limited to RCTs which may have led to exclusion of

potentially relevant findings from well conducted observational studies. Finally, trials published

prior to 2010 were not included in the current review.

Implications

The current review suggests a range of promising interventions, particularly in targeting

depression and anxiety. The use of group-based yoga to treat depression, group-based

mindfulness to treat depression, as well as group-based mindfulness to treat anxiety were


76

ranked as ‘Promising’ interventions based on current empirical research. While no interventions

were ranked as ‘Supported’, those considered ‘Promising’ may progress toward being supported

as advancements are made within these fields of research. Within the short term, a focus on

using mediation and mindfulness-based interventions to treat depression and anxiety may be

beneficial. There is also greater scope for directing funding towards conducting more rigorously-

designed research to examine the use of these interventions to treat mental health conditions

more broadly. It is possible that with a growth in the evidence base for meditation, yoga, and

mindfulness, the benefits of these interventions could be ascertained. For example, one of the

notable and rigorously-conducted studies (Nidich et al., 2018) included in this review indicated

substantial benefits of transcendental meditation to treat PTSD. More of such trials could more

clearly establish the benefits of these interventions to treat a range of mental health conditions.

While the use of traditional first-line psychological and pharmacological interventions would likely

remain the preferred approach for the treatment of these disorders, in some cases where

patients do not respond to or do not engage with first-line treatments, these interventions may

potentially present a feasible option to the use of first-line treatments. At this time, however,

these may be considered emerging interventions that demonstrate potential but are not

considered to be first-line treatments.

When considering meditational, yoga, and mindfulness interventions for the treatment of PTSD,

depression, anxiety, and AUD, it is possible that such treatment approaches may not be suitable

to all individuals. Aspects of the interventions may be more appealing to some and may not be

feasible for others. For example, mindfulness strategies may be useful to prevent hyperarousal

states, but the effects occur gradually over time. Therefore, they may be particularly challenging

for those who have not yet developed appropriate emotion regulation or tolerance skills for

handling high arousal states. Mindfulness-based practices should also be administered with

caution to patients with PTSD, as these practices may distress and destabilise patients.35

As such, the context in which these interventions are recommended to individuals should be

considered before they can be prescribed or recommended. Remaining engaged with the

scientific study of these interventions, however, is likely to be beneficial as the interventions

develop further to target psychological symptoms.

Conclusion

The current evidence base for using meditation, yoga and mindfulness as treatment for PTSD,

depression, anxiety and AUD is lacking, and therefore the most judicious inference that can be

drawn from the results is that the research is of insufficiently high quality to support any direct

recommendations. The findings of this review do, however, provide some guidance on where

future research efforts could be directed, should there be interest in this area. Several


77

‘Promising’ rankings indicate benefits of yoga and mindfulness, but further research is required

prior to making recommendations about the benefits of these modalities in the treatment of

mental health conditions for particular populations. As such, there is an opportunity for funders

and researchers to consider high quality research within this field.


78

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based cognitive therapy compared with maintenance antidepressant treatment in the

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89

Appendix 1

Population Intervention Comparison Outcome (PICO)

framework

Question 1

What role does meditational practice including meditation, transcendental meditation, mantra and

yoga have in mental health treatment options?

When the PICO formula was applied, the question was defined in the following terms.

PICO format:

In people with PTSD, depression, anxiety or AUD, is there evidence that meditation,

transcendental meditation, mantra or yoga will lead to improved mental health outcomes?

P Patient, Problem, Population

I Intervention C Comparison (optional)

O Outcome (“more effective” is not acceptable unless it describes how the intervention is more effective)

Population – adults (i.e. those aged 18 and over)

Patient – adults with one or more of the following:

PTSD

Depression

Anxiety

AUD

Problem – one or more of the following:

PTSD

Depression

Anxiety

AUD

Meditation, transcendental meditation, mantra, or yoga which targets PTSD, depression, anxiety, or AUD

Any comparison (no limits)

Primary outcomes: Improvements in one or more of the following:

PTSD

Depression

Anxiety

Alcohol use

Stress

Wellbeing

Arousal symptoms


90

Question 2

What is the efficacy of mindfulness as a mental health treatment option when compared to

conventional treatment?

When the PICO formula was applied, the question was defined in the following terms:

PICO format:

In people with PTSD, depression, anxiety, or AUD, is there evidence that mindfulness will

improve mental health outcomes in a way that is comparable to conventional

psychological or pharmacological treatment?




Population – adults (i.e. those aged 18 and over)


PTSD

Depression

Anxiety

AUD


PTSD

Depression

Anxiety

AUD

Mindfulness, which targets PTSD, depression, anxiety, or AUD

Conventional psychological or pharmacological treatment


PTSD

Depression

Anxiety

Alcohol use

Stress

Wellbeing

Arousal symptoms


Question 3

91

Is there any benefit for mindfulness, meditation, transcendental meditation, mantra, or yoga to be

used as an adjunct with conventional therapy approaches for PTSD, depression, anxiety, or

AUD?

When the PICO formula was applied, the question was defined in the following terms:

PICO format:

In people with PTSD, depression, anxiety, or AUD, is there evidence that mindfulness,

meditation, transcendental meditation, mantra, or yoga, used as an adjunct with

conventional therapy approaches, will lead to improved mental health outcomes?





PTSD

Depression

Anxiety

AUD


PTSD

Depression

Anxiety

AUD

Population – adults

Mindfulness, meditation, transcendental meditation, mantra, or yoga as an adjunct with conventional therapy approaches, which targets PTSD, depression, anxiety, or AUD

Any comparison (no limits)


PTSD

Depression

Anxiety

Alcohol use

Stress

Wellbeing

Arousal symptoms


92

Appendix 2

Example search strategy

The following is an example of the search strategy conducted in the Embase database:

Step Search terms No of

records

S1 ("mindfulness" or "mindfulness therapy" or "mindfulness-based

stress reduction" or "MBSR").ab,kw,ti.

6851

S2 (depression or "major depression" or "major depressive disorder"

or "MDD").ab,kw,ti.

434806

S3 ("RCT" or "randomised controlled trial" or "clinical trial" or

"random" or "random allocation" or "control trial" or "randomized

controlled trial" or "systematic review" or "meta-analysis" or

"effectiveness trial").ab,kw,ti.

766419

S4 1 and 2 and 3 560

S5 limit 4 to (english language and yr="2010 -Current")

531


93

Appendix 3

Quality and bias checklist

Chalmers Checklist for appraising the quality of studies of interventions.160

Completed

Yes No

1. Method of treatment assignment

Correct, blinded randomisation method described OR

randomised, double-blind method stated AND group

similarity documented

Blinding and randomisation stated but method not described

OR suspect technique (e.g., allocation by drawing from an

envelope)

Randomisation claimed but not described and investigator

not blinded

Randomisation not mentioned

2. Control of selection bias after treatment assignment

Intention to treat analysis AND full follow-up

Intention to treat analysis AND <25% loss to follow-up

Analysis by treatment received only OR no mention of

withdrawals

Analysis by treatment received AND no mention of

withdrawals OR more than 25% withdrawals/loss-to-follow-

up/post-randomisation exclusions

3. Blinding

Blinding of outcome assessor AND patient and care giver

(where relevant)

Blinding of outcome assessor OR patient and care giver

(where relevant)

Blinding not done

Blinding not applicable

4. Outcome assessment (if blinding was not possible)

All patients had standardised assessment

No standardised assessment OR not mentioned

5. Additional notes

Any factors that may impact upon study quality or

generalisability


94

Appendix 4

Evidence profile: Stand-alone meditation and yoga treatments

Authors & year Design Total sample size

Intervention (I) and Comparison (C) and participants for I and C

Number of treatment sessions, treatment duration, treatment frequency, group size

Country Population Mean age (SD)1 Gender (%)

Primary Outcome domain (Measure(s))

Secondary Outcome domain (Measure(s))

MEDITATION

Meditation for PTSD

Group-based meditation for PTSD (compared to non-active comparison)

Bormann,

Thorp,

Wetherell,

Golshan & Lang

(2013)

RCT N = 146 I = Mantram repetition

program (MRP) +

treatment as usual

(TAU)

(n = 71)

C = TAU

(n = 75)

I = MRP intervention

- Delivered to augment TAU in

six 90-min weekly group

sessions.

- Each class was attended by

three to nine veterans

C = TAU

- Case management, as

needed, to evaluate mental

health status and to monitor

treatments and ongoing

medication

USA

Outpatient veterans

with PTSD diagnosis

confirmed by the

medical record and

the CAPS

Mean age = 57 [10.10]

Female gender = 3%

PTSD symptoms:

- CAPS

- PCL

Depressive & anxiety

symptoms:

- BSI-18

Quality of Life:

- SF-12

This randomised controlled trial (RCT) examined the effects of the mantram repetition program (MRP) on treatment of PTSD amongst veterans recruited from an outpatient PTSD clinic. Results

indicated that self-reported PTSD symptoms, as measured using the PCL, decreased by 5.62 points in the MRP group (n = 71) and 2.47 points in the TAU control group (n = 75) (p < .05).

Clinician-rated symptoms measured using CAPS at post-intervention assessment had a clinically significant change (indicated by a 10-point reduction and CAPS score of 45 or less) in symptom

severity in 24% of participants within the MRP group, and 12% of the TAU control group. Effect size calculations of differences in pre-treatment and post-treatment PTSD symptoms indicated

significant but small effect size interactions in symptoms measured by the PCL (p = .05) as well as the CAPS (p = .05). Within the CAPS measurements, the subscale of hyperarousal had a

1 Mean age and SD is given when provided, alternatively age range is provided


95







significant effect size, while re-experience and avoidance did not. Amongst the secondary outcomes, depressive symptoms showed significant reduction in the intervention group (p=.0001),

while anxiety did not (p = .31). No adverse effects of the treatment were reported, and equal drop-out rates (7%) were found for both the MRP and TAU control groups. A limitation of the trial is

the short follow-up of six weeks, which did not include data from the control group, thus preventing group comparison of follow-up data. There was also an overrepresentation of male

participants (97%), limiting the generalisability of results to females.

Group-based meditation for PTSD (compared to active comparison)

Nidich, Mills,

Rainforth,

Heppner,

Schneider,

Rosenthal,

Salerno,

Gaylord-King &

Rutledge

(2018)

RCT N = 203 I = Transcendental

meditation (TM)

(n = 68)

C = Prolonged exposure

(PE)

(n = 68)

C = PTSD Health

education

(n = 67)

I = Transcendental meditation

- Delivered in 12 sessions over

12 weeks, with sessions 1 – 5

consisting of teaching TM

technique, and seven

maintenance sessions.

- Participants were encouraged to

practice two 20-minute TM

sessions at home each day.

C = Prolonged exposure

- Delivered individually in 12

weekly sessions over 12 weeks

C = PTSD health education

- 12 weekly sessions of PTSD

education following manualised

instructions

- Conducted in groups of 2-4

participants

USA

Veterans from the VA

San Diego Healthcare

System with a current

diagnosis of PTSD and

CAPS score of 45 or

higher

Mean age:

TM = 46.4 [14.3]

PE = 48.5 [15.6]

HE = 46.2 [16.4]

Female gender:

TM = 18%

PE = 18%

HE = 15%

PTSD symptoms:

- CAPS

- PCL-M

Depressive symptoms:

- PHQ-9

This three-armed RCT examined the use of transcendental meditation (TM) (n = 68), prolonged exposure (PE) (n = 68), and health education (n = 67) to treat PTSD in US veterans recruited

from the VA San Diego Healthcare system. Results indicated that mean changes in PTSD scores after the three-month intervention was greater than the health education comparison group for

the TM group (d = 0.82) and the PE group (d = 0.49). A Non-inferiority analysis indicated that TM was significantly non-inferior to PE in reducing PTSD symptoms, as measured using the CAPS

and PCL-M (p = .0002). Within the TM group, 61% of participants displayed clinically significant reductions in PTSD symptoms on the CAPS (classified as a 10-point reduction in scores),

whereas 42% of participants in the PE group and 32% of participants in the health education group displayed clinically significant reductions. The amount of clinically significant reduction in the

TM group was statistically significantly greater in the TM group compared to the health education group (p = .001) but was not significantly greater in the PE group compared to the health


96







education group (p = .30). When examining clinically significant symptom reduction using the self-report PCL-M, however, both TM and PE had greater rates of change than the health education

group (p = .0005; p = .029).

Three adverse events were reported within the TM group (two suicide attempts, one non-suicidal death), two in the PE group (one drug overdose, one illness) and two in the health education

group (psychiatric hospitalisations), but none of these were found to be related to the treatment administered. The study was limited by a lack of generalisability or results resulting from having a

sample of primarily male veterans with a baseline level of severe PTSD. There were also relatively high attrition rates reported in all groups, with the highest in the PE group (38%) and the

lowest in the TM group (25%).

Individual meditation for PTSD (compared to active comparison)

Bormann,

Thorp, Smith,

Glickman, Beck,

Plumb, Zhao,

Ackland,

Rodgers,

Heppner, Herz,

Elwy (2018)

RCT N = 173 I = MRP

(n = 89)

C = Present-Centred

Therapy (PCT)

(n = 84)

I = MRP

- Delivered one-on-one in

weekly one-hour sessions

over 8 weeks

- Participants were encouraged

to practise skills as needed to

manage hyperarousal, anger,

irritability, insomnia,

flashbacks, and

numbing/avoidance

C = PCT

- Delivered one-on-one in

weekly one-hour sessions

over 8 weeks

- Participants given daily diary

to record stressors

USA

Veterans Health

Administration Patients

met DSM-IV-TR criteria

for PTSD, and all met

symptom severity cut-

off scores of ≥45 on the

CAPS and ≥50 on the

PCL-M

Mean age:

MRP = 48.3 [14.63]

PCT = 49.5 [14.50]

Female gender:

MRP = 18%

PCT = 12%

PTSD symptoms:

- CAPS

- PCL-M

Depressive symptoms:

- PHQ-9

Spiritual Well-being:

- Functional

Assessment of

Chronic Illness

Therapy–Spiritual

Well-Being

questionnaire

Quality of Life:

- WHOQoL-BREF

This RCT compared two treatments that were conducted on an individual basis; mantram repetition (n = 89) and present-centred therapy (PCT) (n = 84) in patients from the Veteran Health

Administration. Results indicated significantly greater improvement in CAPS scores within the mantram group when compared to the comparison group, at the post-treatment assessment

(between-group difference = -9.98, 95% CI = -3.63, -16.00, p = .006) as well as at the two-month follow-up assessment (between group difference = -9.34, 95% CI = -1.50, -17.18, p = .04). In

the mantram group, 75% of participants (n = 49) displayed clinically significant improvement in CAPS scores, compared to 61% of the PCT group (n = 43), which was not a significant difference.

Self-reported PTSD symptoms on the PCL-M indicated a significant difference between groups at post-treatment assessment (-5.83, 95% CI = -1.73. -9.93, p = .04) with the mantram group

showing greater reduction in symptoms, but not at the two-month follow-up assessment (p = 0.25). At the post-treatment assessment, there was no significant difference in the number of

participants who no longer met criteria for PTSD between the mantram group (48%, n = 32) and the PCT group (35%, n = 24). Amongst participants who completed the two-month follow-up


97







assessment, 59% of the mantram group no longer met criteria for PTSD (n = 36), compared to 40% of the present-centred therapy group (n = 26), which represented a significant difference (𝑋2

= 4.55, p < .04).

Four adverse events were reported, but the authors stated they were unrelated to the study treatments. The mantram group displayed higher attrition rates than the PCT group at both post-

treatment (22% compared to 14%) and follow-up assessments (26% compared to 15%) but these difference were not significant. Limitations of the trial include a use of a self-selected sample of

veterans from only two centres within the US, thus somewhat limiting the generalisability of results.

Meditation for depression

Group-based meditation for depression (compared to non-active comparison)

Vasudev,

Arena, Burhan,

Ionson, Hirjee,

Maldeniya,

Wetmore, &

Newman (2016)

RCT

(preliminary

analysis)

N = 51 I = Automatic self-

transcending

meditation (ASTM)

(n = 26)

C = Waitlist TAU

(n = 25)

I = ASTM

- Four two-hour meditation

sessions in groups of 3-8,

followed by 11 one-hour

weekly reinforcement

sessions.

- Participants were asked to

practise ASTM at home 20-

minutes a day and attend

75% of reinforcement

sessions

C = Continued existing

antidepressants and/or therapy

and were offered meditation

training after the study period

Canada

Adults between 60-85

years old diagnosed

with mild-to-moderate

MDD (either unipolar

or bipolar depression)

based on a HAMD-17

score of 8-22

Mean age:

Meditation = 68.33

[6.12]

Control = 66.95 [6.31]

Female gender:

Meditation = 53%

Control = 73%

Affective

symptoms of

depression:

- HAMD-17

Geriatric depression:

- GDS

Geriatric anxiety:

- GAI

Quality of life:

- QOLSV

This RCT examined the effectiveness of a training program involving the use of automatic self-transcending meditation (ASTM) to treat late-life depression in seniors aged 60 and above

recruited from primary and secondary health centres in Ontario. The trial was ongoing at the time of publication, but preliminary analyses revealed that the primary outcome measure of

depressive symptoms, the HAMD-17 score, was significantly reduced in the ASTM condition compared to TAU (p < .05). Secondary depression outcome measures also demonstrated significant

changes over time, with significant interactions between score and condition in both the GDS (p < .05) and GAI (p < .05). Quality of life improved throughout the study period in both conditions

(p < .05).


98







The mean dropout rate was 18% (22% for ASTM and 13% for TAU), and none of the dropouts were related to adverse events. The small sample size was a limitation of the trial, as well as the

lack of long-term follow-up to determine enduring effects of the intervention. This was a preliminary analysis of an RCT, and thus does not provide the full analysis, which further limits

interpretation of the results.


No studies identified

Meditation for anxiety

Group-based meditation for anxiety


Individual meditation for anxiety


Meditation for combined depression and anxiety

Group-based meditation for heterogeneous groups of depression and/or anxiety


Individual meditation for heterogeneous groups of depression and/or anxiety


Meditation for AUD


99







Group-based meditation for AUD


Individual meditation for AUD


YOGA

Yoga for PTSD

Group-based yoga for PTSD (compared to non-active comparison)

Jindani, Turner,

Khalsa (2015)

RCT N = 80 I = Kundalini Yoga (KY)

(n = 59)

C = Waitlist (WL)

(n = 21)

I = Kundalini yoga classes

- Weekly 90-minute group

classes for eight weeks,

including a 15-minute daily

home practice guided by a

YouTube video

C = WL received the same

intervention at a later date

All participants were permitted

concurrent outside treatment

provided it did not have a

contemplative component

Canada

Adults with score

above 57 on the PCL-

17

Median age:

41

(Age range: 18-64)

Female gender:

KY = 93%

WL = 76%

PTSD symptoms:

PCL

Perceived Stress:

- PSS

Depression, Anxiety,

Stress:

- DASS-21

This RCT was conducted to compare the effects of an eight-week Kundalini Yoga intervention on PTSD symptoms (n = 59), compared to a waitlist group (n = 21) in adults recruited from a

community population in Toronto. Results indicated that post-intervention PTSD symptoms, as measured using the PCL, were significantly lower in the yoga group compared to the watilist

group (p < .05). Secondary outcomes of perceived stress decreased by about half, which was significantly greater than reductions in the waitlist group (p < .05). DASS score reductions were

also significantly greater in the yoga group in the domains of anxiety (p < .05) and stress (p < .05).


100







The overall dropout rate for the trial was 30%, but substantially more dropouts were observed in the yoga group (51%). The lack of follow-up assessment in this trial was considered a limitation,

as the long-term impact of the intervention could not be determined.

Mitchell, Dick,

DiMartino,

Smith, Niles,

Koenen, Street

(2014)

Reddy, Dick,

Gerber, &

Mitchell (2014)

RCT N = 38 I = Kripalu-based yoga

(n = 20)

C = Assessment

control group

(n = 18)

I = Kripalu-based yoga classes

- Participants were given the

option to attend 12 weekly

yoga sessions or 12 twice-

weekly sessions over 6

weeks, but were not allowed

to switch from one group to

the other once the

intervention had begun.

- All sessions were 75-minutes

long

C = Assessments

- Met once per week for 12

weeks in groups of 4-5 to

complete weekly

questionnaires

USA

Veteran and civilian

adult women who

scored positive on the

Primary Care PTSD

screen (PC-PTSD)

Mean age:

44.37 [12.37]

Female gender:

100%

PTSD severity

- PC-PTSD

- PCL

Depressive

symptoms:

- CES-D

Anxiety symptoms:

- STAI

Alcohol use:

- AUDIT

Participants in this RCT received either Kripalu yoga-based intervention (n = 20) targeting PTSD or subthreshold PTSD and completed weekly assessments, or completed the assessments only

(n = 18). Participants included veteran and civilian adult women recruited through a Veterans Affairs (VA) medical centre. Clinically significant decreases in PCL total scores were observed in

both the intervention and control groups, with no significant effect of group on symptom reduction (p = .591). The yoga group had significant reductions in PCL scores throughout the course of

the intervention (p = .003), while the assessment control group had marginally significant decreases (p = .02). When examining specific subscales of the PCL, there were also no significant

effects of group on reductions in re-experiencing (p = .409), avoidance (p = .806), and hyperarousal (p = .850). Decreases in depressive and anxiety symptoms, as measured by the CES-D and

STAI, also demonstrated no significant effect of group, although STAI scores decreased significantly for both groups. A secondary analysis of the results found that immediately after the 12-

week intervention and at the 1-month follow-up, alcohol use (AUDIT) decreased in the yoga group and increased in the control group. However the difference between these groups was not

statistically significant.

No adverse events were reported, but 32% of randomised participants withdrew from the trial or were lost to follow-up, although dropout rates were similar for both groups. Participants who did

not complete treatment or control assessments had higher PCL scores (marginally significant at p = .032) than those who completed treatment, suggesting that more severe symptomatology

may have decreased tolerance for participation in the trial. Limitations of the trial included a small sample size, a short follow-up period of one month, and a female-only sample, which reduces

generalisability to male populations.


101







Quinones,

Maquet, Velez,

Lopez (2015)

RCT N = 100 I = Satyananda Yoga

(n = 50)

C = Continued the

regular demobilisation

program

(n = 50)

I = Satyananda yoga classes

- Twice-weekly one-hour

classes taught for 16 weeks

- Participants were encouraged

to practice at home using a

CD and handbook

C= Mandatory ordinary assistance

protocol for reintegrating individuals

- Monthly appointment with a

trained psychologist designed

to follow up on individual

progress in the reintegration

process

- Placed on a waiting list for

yoga classes

Columbia

Ex-combatants with

diagnosis of PTSD

confirmed by a

minimum total PCL

score of 44.

Mean age: N.A.

Female gender:

I = 30%

C = 24%

PTSD symptoms:

- PCL

This trial investigated the use of Satyananda Yoga as a treatment for PTSD symptoms in adults recruited from a population of illegal armed group ex-combatants reintegrating after being

exposed to armed conflict in Columbia. Both the yoga group (n = 50) and the control group (n = 50) demonstrated significant decreases in PTSD symptoms according to the PCL. The yoga

group experienced a large treatment effect, as indicated by a large effect size (d = 1.15), while the control group showed a medium effect size (d = 0.42). Large effect sizes were also found for

all symptom clusters for the yoga group, including re-experiencing (d = 1.40), avoidance (d = 1.09), and hyperarousal (d = 0.99). The clinical improvement in PTSD symptoms was significantly

greater in the yoga condition compared to the control condition (p < .05). At the post-intervention assessment, the mean PCL score for the yoga condition (38.84) was below the clinical cut-off of

44 for diagnosing PTSD, while the mean score for the control condition (48.26) was above the cut-off.

No serious adverse effects were reported, but two participants reported minor headaches. A limitation of this trial was the short follow-up period of one month. There were also higher

proportions of males than females in both the intervention group (70%) and the control group (76%).

Reinhardt,

Taylor,

Johnston,

Zameer,

Cheema,

Khalsa

(2018)

RCT N = 51 I = Kripalu Yoga

(n=26)

C = Waitlist control

(n=25)

I = Kripalu yoga

- Twice weekly 90-minute

group yoga sessions over 10

consecutive weeks including

discussion on specific

themes.

USA

Veterans or active

duty military personnel

with PTSD diagnosis

based on DSM-IV-TR

Mean age:

PTSD symptoms:

- PCL

- CAPS

Distress:

- IES-R


102








practice yoga at home for 15-

minute with audio recording

C = WL group could chose to

receive the same yoga intervention

at a later date

Yoga = 44.13 [13.97]

WL = 56.15 [1.39]

Assessment group =

46.58 [12.66]

Female gender:

Yoga = 8%

WL = 15%

Assessment group =

17%

Participants for this RCT were recruited from VA hospitals, and included veterans and active duty military personnel, with the aim of treating PTSD symptoms. Results of the trial indicated that

while participants in the yoga and comparison groups both had average CAPS scores in the severe range, the yoga group’s average symptom severity dropped to the moderate range after the

intervention, and the comparison group’s remained in the severe range. Both groups had reductions in total CAPS scores and subscales, but only the subscale of re-experiencing yielded

significant differences (p = .02). There were no significant between-group differences in total CAPS scores when comparing the yoga and comparison groups. Self-report PCL-M scores

indicated a reduction in PTSD symptoms in the yoga group and slight increase in the comparison group, but these differences were not significant. The waitlist yoga group, which included

participants who chose to receive the yoga intervention at a later date (n = 7) demonstrated significant reductions in CAPS past-month scores (p = 0.02).

A major limitation of this trial was the high dropout rate of 51%. Over half the yoga group (62%) dropped out of the treatment, and 46% of the waitlist yoga group dropped out.

Seppala,

Nitschke,

Tudorascu,

Hayes,

Goldstein,

Nguyen,

Perlmanm &

Davidson

(2014)

RCT N = 21 I = Sudarshan Kriya

yoga (n = 11)

C = Waitlist

(n = 10)

I = Sudarshan Kriya yoga

- Daily three-hour group yoga

sessions for seven days

C = Waitlist group

- Received the same

intervention at a later date

Participants in both groups were

encouraged to continue concurrent

treatment

USA

Male veterans with

service in Afghanistan

or Iraq

Mean age:

Yoga = 28.09 [2.91]

WL = 29.20 [6.66]

Female gender:

0%

PTSD symptoms:

- PCL-M

Anxiety and depression:

- MASQ

This RCT examined the effects of Sudarshan Kriya yoga on male veterans recruited from military and veteran organisations with symptoms of PTSD, compared to a waitlist control group. While

clinical diagnosis of PTSD was not in the inclusion criteria, mean scores on the PCL-M were above the clinical cut-off of in both groups. Results indicated that the yoga group had significantly

fewer PCL-M symptoms at the post-intervention assessment, 1 month post-intervention, and 1 year post-intervention compared to pre-intervention assessment. The differences between the

yoga group and watilist group were significant and demonstrated large effect sizes at post-intervention (d = 1.16, 95% CI = 0.20, 2.04), 1 month post-intervention (d = 0.94, 95% CI = 0.00, 1.80),


103







and 1 year post-intervention (d = 1.00, 95% CI = 0.05, 1.86). Similar results were found for anxiety and depression (MASQ) scores (d = 0.96, 95% CI = 0.02, 1.82; d = 1.11, 95% CI = 0.15, 1.98;

d = 0.99, 95% CI = 0.05, 1.86).

No adverse events were reported by participants. Limitations of the trial included a small sample size as well as an all-male sample, both of which limit the generalisability of the findings.

Twenty-five percent of the sample was lost at the 1 year follow-up, but an intent to treat analysis was used to replace missing data.

Individual yoga for PTSD


Yoga for depression

Group-based yoga for depression (compared to non-active comparison)

Buttner, Brock,

O’Hara, &

Stuart (2015)

RCT N = 57 I = Gentle vinyasa flow

yoga classes

(n = 28)

C = Waitlist

(n = 29)

I = Vinyasa flow yoga classes

- 16 one-hour yoga classes

over eight weeks


practice at least once a week

at home with a DVD including

a 30-minute yoga routine

C = WL group

- Received the same treatment

at a later date

USA

Adult females who had

given birth within 12

months and met

criteria for MDD using

a HDRS score greater

than 12.

Mean age:

Yoga = 29.81 [5.17]

Control = 32.45 [4.78]

Female gender:

100%

Depression:

- HDRS

Depression:

- PHQ-9

- SCID-I

- IDAS

Health-related quality of

life:

- SF-36

This RCT investigated the effectiveness of a postpartum yoga class (n = 28) compared to a waitlist group (n = 29) amongst women aged between 18 and 45 who had given birth within the past

12 months, identified and recruited using public birth records. Depression symptoms (HDRS) decreased significantly within the entire sample (p < .001), but the decrease was greater for the

yoga group than for the waitlist group (p = .005). In the yoga group, 78% of participants reported clinically significant change at the post-treatment assessment, compared to 59% of participants

in the waitlist group.


104







There was no long-term follow-up reporting the enduring effects of the intervention, which was a limitation of the trial. Generalisability was also limited by the non-representative sample (women

who had recently given birth).

Chu, Wu, Lin,

Chang, Lin, &

Yang (2017)

RCT N = 26 I = Yoga group

(n = 13)

C = Waitlist - Instructed

not to engage in any

yoga practice and

maintain usual level of

physical activity

(n = 13)

I = Yoga classes

- Twice weekly 60-minute yoga

classes over 12 weeks.

- Classes comprised of three to

five participants

C = Waitlist

- Provided with a free 12-week

yoga program following post-

test assessment completion

Taiwan

Adult females with

mild to moderate

depressive symptoms,

as characterised by

BDI-II score of 14-28

Mean age:

Yoga = 33.08 [9.11]

Control = 32.38 [8.27]

Female gender:

100%

Depressive

symptoms:

BDI-II

Perceived stress:

- PSS

Heart rate variability

- ECG heart rate

recording

This trial aimed to examine the effectiveness of a 12-week yoga program (n = 13) to decrease depressive symptoms and heart rate compared to a waitlist group (n = 13) in depressed women

recruited from a university and the surrounding community. There was a significant group x time interaction effect for depressive symptoms but not for perceived stress. Results indicated that

the yoga group reported significantly reduced BDI-II scores (p=.005) while the waitlist group reported no significant change. Perceived stress, assessed using the perceived stress scale (PSS)

was also significantly reduced in the yoga group (p=.003) and not in the waitlist group.

No adverse events were reported in response to the yoga intervention. The trial was limited by a small sample size and lack of follow-up data to determine long-term effects of the yoga

intervention.

Field, Diego,

Medina,

Delgado, &

Hernandez

(2012)

RCT N = 84 I = Yoga

(n= not reported)

I = Massage therapy

(n= not reported)

C = Standard prenatal

care

(n = not reported)

I = Twice weekly 20-minute group

yoga sessions for 12 weeks.

Groups consisted of approximately

eight participants

I = Twice weekly 20-minute

massage

C = Standard prenatal care

USA

Adult females in

second trimester of

pregnancy between 18

and 22 weeks with a

diagnosis of

depression based on

SCID

Mean age:

Depression:

- CES-D

Anxiety:

- STAI


105







26.6

(Age range: 18-40)

Female gender:

100%

This trial examined the efficacy of yoga, massage therapy, and standard prenatal care amongst adult females in their second trimester of pregnancy who were screened for depression at two

medical school prenatal ultrasound clinics. Results indicated significant reductions in depression, as measured using the CES-D, and anxiety (measured using the STAI) in both the yoga group

(p < .001) and the massage group (p < .001) but not the control group. The difference in mean CED-D scores at baseline and post-intervention was greater in the massage group (mean

difference = 11.77) than in the yoga group (mean difference = 8.23) but a significance test was not conducted, making it unclear whether these differences represented a statistically significant

reduction in depression.

The trial was limited by a lack of follow-up, as well as poor generalisability as the sample consisted only of pregnant females.

Kinser,

Bourguignon,

Whaley,

Hauenstein, &

Taylor (2013)

Kinser, Elswick,

& Kornstein

(2014)

RCT N = 27 I = Hatha yoga

(n = 15)

C = Attention-control

(n = 12)

I = Hatha yoga classes

- Weekly 75-minute group yoga

class for 8 weeks

- Daily home practice with a

DVD and handouts

C = Health education classes


health education class for

eight weeks

USA

Adult females with a

diagnosis of MDD or

dysthymia based on

MINI or a score of 9 or

above on PHQ-9

Mean age:

43.26 [15.57]

Female gender:

100%

Depression

severity:

- PHQ-9

Stress:

- PSS-10

Anxiety:

- STAI

Rumination:

- RSS

This trial tested Hatha yoga as a treatment for women with MDD recruited from a community population in the US. A subsequent paper reported the results of a one-year follow-up. Initial results

indicated that all participants had decreasing levels of depression over the course of the 8-week trial, but there was no significant difference in reductions in the yoga group compared to the

comparison group (as indicated by PHQ-9 scores). There were also no significant differences in levels of stress or anxiety between the two groups. The only outcome that demonstrated a

significant group x time effect was rumination, which demonstrated greater reductions in the yoga group compared to the comparison group.

The 1-year follow-up analysis (Kinser, Elswick & Kornstein, 2014) included nine participants from the original trial, tested on all outcome measures one year after the completion of the

intervention. Participants in both groups experienced a decrease in depression, but the yoga group had a significantly greater reduction in depression severity (p < .001) and rumination (p =

.017). There was no statistically significant difference in reductions in other outcomes, including perceived stress and anxiety.


106







The limitations of this trial include a small sample size and a high drop-out rate, both in the primary analysis (33%) and in the follow-up analysis (66%).

Prathikanti,

Rivera,

Cochran,

Tungol,

Fayazmanesh,

Weinmann

(2017)

Parallel RCT N = 38 I = Hatha yoga

(n = 20)

C = Attention Control

(AC)

(n = 18)


- Twice weekly 90-minute yoga

classes for eight weeks

C = Yoga history module

- 8 twice weekly 90-minute

yoga history module with

short lectures and

documentary clips focussing

on historical figures of the

yoga tradition

USA

Adults who met

diagnostic criteria for

mild-to-moderate

major depression

using MINI and BDI-II

score of 14-28

Mean age:

43.40 [14.8]

Female Gender:

68%

Depressive

symptoms:

BDI-II

This RCT compared a group yoga intervention (n = 20) to an attention control education group (n = 18) for treating mild-to-moderate depression in individuals recruited from the local community

and outpatient clinics. The group-time interaction was found to be significant, indicating that participants in the yoga group displayed a greater reduction in depression symptoms on the BDI-II

when compared to the comparison group (p = .034). Between the baseline and 8-week assessments, BDI scores in the yoga group decreased by an average of 9.47 points (95% CI = 6.57,

12.37), while scores in the comparison group decreased by an average of 2.99 (95% CI = 0.45, 6.43). The difference between the two groups was statistically significant (p = .005), and the

effect size was large (d = -0.96, 95% CI = -1.81, -0.12). Among those who completed the 8-week intervention, 60% achieved remission, while in the comparison group 10% achieved remission

(remission was defined by a BDI score of 9 or less at the final assessment).

Adverse events included two reports of musculoskeletal injury that were unrelated to yoga exercises, and musculoskeletal discomfort during yoga classes, which resolved throughout the course

of the intervention. The trial was limited by a small sample size and lack of follow-up assessment.

Uebelacker,

Battle, Sutton,

Magee, & Miller

(2016)

RCT N = 20 I = Prenatal yoga

program

(n = 12)

C = Mom-baby

wellness workshop

(n = 8)

I = Prenatal yoga classes


prenatal yoga classes for nine

weeks

C = Mom-baby wellness workshop


workshops focussed on

USA

Adult females 12-26

weeks pregnant with

minor or major

depression based on

scores between 7 and

20 on QIDS

Mean age:

Depression

severity:

- QIDS

- EPDS

Injuries

- Asked participants

in the intervention

group if they had

experienced any

injuries or medical

problems due to

yoga


107







postpartum health and

general wellness

28.4 [5.8]

Female gender:

100%

Amount of yoga:

- Amount of home

yoga practice

This pilot RCT aimed to reduce depression amongst pregnant females with depression who were recruited from community locations and OB/GYN practices. The trial compared prenatal yoga

(n = 12) to perinatal health workshops (n = 8). Both the QIDS and EPDS showed improvement in depression severity in both groups, but these changes were not significant. The yoga group had

greater reductions in depression severity according to the QIDS and EPDS, with medium effect sizes, but these differences were not statistically significant.

Limitations of this trial included a small sample size and a lack of blinding of assessors despite use of a clinician-rated assessment depression severity. There were additional methodological

limitations that introduced risk of bias, including an unknown randomisation process and lack of intent-to-treat analysis.

Individual yoga for depression


Yoga for anxiety

Group-based yoga for anxiety


Individual yoga for anxiety (compared to non-active comparison)

Bidgoli,

Taghadosi,

Gilasi, &

Farokhian

(2016)

RCT N = 80 I = Sukha pranayama

breathing exercises

(n = 40)

C = Routine coronary

angiography-related

care services

(n = 40)

I = Sukha pranayama

- Five minute breathing

exercise before undergoing

coronary angiography

procedure

C = Routine angiography care

without breathing exercises

Iran

Adults undergoing

coronary angiography

for the first time with

an anxiety score of 43

or greater based on

SAI

Mean age:

Anxiety:

- SAI


108







Yoga = 55.50 [7.36]

Control = 62.70 [6.28]

Female gender:

Yoga: 55%

Control: 45%

This RCT examined the effects of a single dose of pranayama breathing on anxiety in patients undergoing coronary angiography recruited from a hospital in Iran. The experimental group had a

session of sukha pranayama breathing before undergoing the surgery, while the comparison group received only the routine pre-angiography care. The experimental group had significant

reductions in anxiety scores half an hour and one hour after the intervention (p < .001). The comparison group also experienced a slight, but non-significant, decrease in anxiety. There were

also between group differences in anxiety levels in the experimental and comparison groups at all time points (p < .05).

The trial included only a single intervention session, which differs from other trials in the review which implemented multiple treatment sessions. This should be considered when comparing this

trial with others included in the table. There was no long-term follow-up to track if the decrease in anxiety continued or if patients continued to utilise breathing exercises to relieve anxiety.

Generalisability was also limited due to the sample comprising of coronary angiography patients, who may have different health profiles from healthy adults.

Yoga for combined depression and anxiety

Group-based yoga for combined depression and anxiety (compared to non-active comparison)

Davis,

Goodman,

Leiferman,

Taylor, &

Dimidjian (2015)

RCT N = 46 I = Ashtanga Vinyasa

yoga and TAU

(n = 23)

C = TAU

(n = 23)

I = Ashtanga Vinyasa yoga classes


classes over eight weeks

C = TAU


report outside treatments

received

USA

Adults females who were

pregnant (up to 28

weeks) with depression

score of nine or greater

on EPDS, and/or anxiety

score of 35 or greater on

STAI

Mean age:

30.15 [4.92]

Female gender:

100%

Depression:

- EPDS

Negative affect:

- PANAS-N

State and trait

anxiety:

- STAI


109







This trial randomly assigned pregnant women with symptoms of depression and anxiety to an Ashtanga Vinyasa yoga program (n = 23) or TAU (n = 23) after they were recruited through

community advertisements and health care provider referral. Both groups demonstrated a significant improvement in depression scores (EPDS) but there was no significant difference in the

improvement between the yoga and comparison groups (p = .55). There was a significantly greater reduction in negative affect (PANAS-N) in the yoga group compared to the comparison group,

indicating that the yoga group had less negative affect (p = .011). Both state and trait anxiety reductions were significant within each group, but there was no significant group difference in these

reductions.

Only one participant reported medical complications, in the form of premature labour, but this was not linked to the yoga intervention. The trial’s limitations include potentially reduced

generalisability due to a sample including only pregnant females. There was also a small sample size, and results did not separate scores for those with anxiety symptoms from those with

depressive symptoms, thus making it difficult to isolate the effects of the intervention on either disorder.

Falsafi (2016) Repeated

measures RCT

N = 90 I = Hatha yoga

(n = 23)

I = Mindfulness

(n = 21)

C = Waitlist

(n = 23)



classes for eight weeks

- Yoga materials provided to

practice at home

I = Mindfulness and self-compassion

intervention


mindfulness training for eight

weeks

C = Waitlist

- Only assessments with option to

receive intervention that

provided best outcomes after

the trial

USA

Adult students with a

diagnosis of depression

and/or anxiety

Mean age:

22.1

(Age range: 18-50)

Female gender:

86%

Depression:

- BDI

Anxiety:

- HAS

Stress:

- Student-Life

Stress Inventory

This trial investigated Hatha yoga (n = 23) and mindfulness (n = 21) treatments, in comparison to a waitlist group (n = 23). Participants were recruited from a mid-size public US university

Compared to the waitlist group, depression, anxiety, and stress symptoms scores in the yoga group reduced significantly from pre-intervention to follow-up assessment (p < .01). The scores

remained similar at the 12-week follow-up assessment compared to post-intervention assessment.

The dropout rate for the trial was 20%, and limitations included a potential lack of generalisability due to the sample being 85% female and 90% Caucasian.


110







Kuvacic, Fratini,

Padulo, Iacono,

& Giorgio (2018)

RCT N = 30 I = Yoga

(n = 15)

C = Pamphlet

(n = 15)

I = Yoga classes

- Twice-weekly group yoga

classes over eight weeks

C = Pamphlet

- Received a pamphlet about

chronic low back pain

Croatia

Adults with pervasive

chronic low back pain

and depression and

anxiety based on Zung

self-rating depression

and anxiety scales

Mean age:

34.30 [4.52]

Female gender:

47%

Depression:

- SDS

Anxiety:

- SAS

Low back pain:

- ODI-I

Pain:

- NRS 0-10

This trial compared an 8-week yoga program (n = 15) with an informational pamphlet (n = 15) in adults with chronic low back pain diagnosed with depression and anxiety. Results indicated a

significant time x group interaction (p = .021). The yoga group had a significant decrease in depression scores (p < .01) whereas the comparison group did not, and the difference between these

groups was statistically significant (p <.001). For anxiety, only the yoga group showed a significant decrease (p < .01), but the between group difference when compared to the comparison group

was not significant. The yoga group demonstrated significant decreases in pain levels and this was significantly different between groups (p < .001).

Limitations of this trial include a small sample size and a lack of follow-up assessment, which limited the information known about the long-term effectiveness of this intervention, as well as a

small sample size.

Rani, Tiwari,

Singh, &

Srivastava

(2012)

RCT N = 150 I = Yoga nidra and

pharmacotherapy

(n = 65)

C = Pharmacotherapy

only

(n = 61)

I = Yoga nidra classes

- Daily 35-minute group yoga

classes five days a week for six

months

C = Pharmacotherapy only

India

Adult females between

18 and 45 years with

menstrual irregularities

Mean age:

Yoga = 27.67 [7.85]

Control = 26.58 [6.87]

Female gender:

100%

Anxiety:

- HAM-A

Depression:

- HAM-D


111







This trial examined the use of yoga nidra as a treatment for anxiety and depression in females with menstrual disorder who were recruited from a medical university. Participants were allocated

to the yoga nidra group (n = 65) or the comparison group with pharmacotherapy only (n = 61). Results showed significant improvement in anxiety and depression symptoms six months after the

yoga intervention in those with mild or moderate anxiety and depression at baseline (mild: p < .01; moderate: p < .02). In those who started the intervention with severe anxiety and depression

symptoms, there was no significant change in scores after six months. When compared to the comparison group, the yoga group reported significantly greater improvement in anxiety (p < .003)

and depression (p < .02).

Limitations of this trial include the fact that not all participants had clinical levels of depression and anxiety when assessed at baseline. In the intervention group, 86% reached criteria for clinical

anxiety, 89% for clinical depression. In the comparison group, 90% with anxiety and 84% had depression. Results did not differentiate the effects of the treatment on those with and without

clinical levels of anxiety and depression. There was also high levels of attrition, with 23% of the comparison group and 15% of the intervention group lost to follow up. Additionally, it was not clear

from this trial if the medication prescribed was targeting psychological symptoms or menstrual irregularities.

Individual yoga for combined depression and anxiety (compared to non-active comparison)

de Manincor,

Bensoussan,

Smith, Barr,

Schweickle,

Donoghoe et al.

(2016)

RCT (single

group cross-

over design)

N=101 I = Yoga intervention

plus TAU

(n = 47)

C = Waitlist control plus

TAU

(n = 54)

I = Yoga classes

- Four individual one-hour

consultations/lessons over a

six-week period with a qualified

yoga teacher.

- Individualised yoga practice was

developed for each participant

for home practice according to

their presenting symptoms,

needs, abilities, goals, and

circumstances. Yoga practice

included postures, movement,

breathing exercises, relaxation,

mindfulness and meditation,

cultivation of positive values,

thoughts, attitudes, and lifestyle

changes.

C = 6-week TAU only (waitlist)

Australia

Adults with at least mild,

moderate, or severe

depression or anxiety

according to the DASS-

21

Mean age:

Yoga = 39.5 [11.3]

Control = 38.2 [11.2]

Female gender:

Yoga = 87%

Control = 74%

Depression and

anxiety:

- DASS-21

Psychological

distress/wellbeing:

- K10

- SPANE

Resilience:

- CD-RISC 2

Health:

- SF-12

Participants for this RCT were recruited through referrals from local psychologists, GPs, mental health service providers, advertisements, email newsletters, and social media. A total of 107

participants were randomised into a yoga intervention (n = 47) or waitlist group with TAU (n = 54) to treat depression and/or anxiety, however there were six post-randomisation exclusions.

Assessments were taken at baseline, at the end of the intervention, and six weeks after the end of the intervention. The post-intervention analysis included data from 101 participants (47


112







intervention, 54 waitlist), while follow-up analyses included the 37 intervention group participants. At six-week follow-up, statistically significant differences were observed between the yoga and

watilist groups on reduction of depression scores (-4.30; 95% CI: -7.70-0.01; p = .01). Differences in reduction of anxiety scores were not significant (-1.91; 95% CI: -4.58-0.76; p = .16).

Statistical significant differences in favour of the yoga group were observed on total DASS (p = .03), K10, SF12 mental health, SPANE, FS and resilience scores (p < .01). Differences in stress

and SF12 physical health scores were not statistically significant.

No adverse effects related to the yoga intervention were reported. Limitations of the current study include that the majority of participants (n = 61) presented with comorbidity of elevated

symptoms in both depression and anxiety. The extent to which the yoga intervention implemented in this study targeted depression, anxiety or both is unclear and the effects on targeted

conditions cannot be separated. Study measures were all self-reported which may introduce reporting bias. Some participants were eligible before randomisation, but because re-assessment

occurred before commencing the intervention, some participants were no longer eligible only a single assessment for elevated symptoms of depression and/or anxiety scores on DASS subscales

was used at screening, they were no longer eligible at commencement of the trial. Using diagnostic criteria for assessment to determine eligibility at the screening stage is recommended.

Yoga for AUD

Group-based yoga for AUD (compared to non-active comparison)

Bichler,

Miedermeier,

Fruhauf,

Langle,

Fleischhacker,

Mechtcheriakov,

Kopp (2017)

Cross-over

RCT

N = 16 I = Yoga-gymnastic

(YG)

(n = 16)

C = Nordic walking

(NW)

(n = 16)

C = Passive control

(PC)

(n = 16)

YG = Hatha yoga classes

- 60-minute of training in Hatha-

yoga, a practice of postures,

controlled breathing and

meditation.

- Patients performed exercise

with intensity of 11-14 on

Rating of Perceived Exertion

- Groups of 3-5

NW = Nordic walking

- 60-minute Nordic walking

using sticks to perform

moderate intensity outdoor

walking on uneven terrain

- Groups of 3-5

PC = Sitting in gym while reading

magazines

Austria

Inpatients diagnosed

as alcohol dependence

with clinical observable

cravings, but currently

abstinent without

relapse

Mean age:

47.3 [7.9]

Female gender:

20%

Alcohol craving:

- AUQ

Affective

responses:

- Feeling Scale

- Felt Arousal

Scale


113







- Groups of 3-5

This cross-over RCT investigated the use of single session interventions consisting of yoga, Nordic walking, and reading magazines with inpatients recruited during withdrawal treatment, after

they had undergone alcohol detoxification at psychiatric hospitals. All 16 participants participated in all three activities in randomised orders, with a one-week wash-out period between activities.

Results indicated no significant changes in alcohol cravings (as measured by the AUQ) over time in any of the groups.

This trial involved only single session interventions limiting the ability to determine the ongoing efficacy of the interventions. The small sample size and 80% male sample also limited the

generalisability of these results.

Individual yoga for AUD


YOGA/MEDITATION

Yoga/meditation for PTSD


Yoga/meditation for depression (compared to non-active comparison)

Tolahunase,

Sagar, Faiq, &

Dada (2018)

RCT N = 58 I = Yoga and

meditation, in addition

to routine drug

treatment

(n = 29)

C = Routine drug

treatment

(n = 29)

I = Yoga and meditation

intervention

- 12-week yoga-and-mediation-

lifestyle intervention

- Five 120-minute sessions per

week of theory and practice

C = Continued routine drug

treatment

India

Adults diagnosed with

MDD based on DSM-5

criteria and on routine

drug treatment for at

least six months

Mean age:

Intervention = 36.94

[8.94]

Control = 39.10 [9.26]

Depression

severity:

- BDI-II


114







Female gender:

Intervention = 55%

Control = 52%

This RCT examined a mixed yoga and meditation intervention along with routine drug treatment in adults with MDD who were recruited from an outpatient psychiatric unit in New Delhi. The

intervention group (n = 29) was compared to a group with only routine drug treatment (n = 29). There was a significant decrease in BDI score in the intervention group compared to the

comparison group (-5.83, 95% CI = -7.27, -4.49, p < .001). The results also indicated that females in the intervention group demonstrated significantly more clinical improvement than males, with

a larger difference of change (females: -6.12, p = .003; males: -3.86, p = .032).

This trial was limited by a lack of long-term follow-up, which makes it unclear whether the benefits of this intervention persisted long-term.

Yoga/meditation for anxiety


Yoga/meditation for mixed depression and anxiety


Yoga/meditation for AUD


N.B:

AUDIT = Alcohol Use Disorder Identification Test; AUQ = Alcohol Urges Questionnaire; BDI-II = Beck Depression Inventory; BSI -18 = Brief Symptom Inventory 18; CAPS = Clinician Administered

PTSD scale; CD-RISC = Connor-Davidson Resilience Scale; CES-D = Center for Epidemiologic Studies Depression Scale; DASS-21 = Depression, Anxiety and Stress Scale; DUDIT = Drug Use

Disorders Identification Test; EPDS = Edinburgh Postnatal Depression Scale; GAI = Geriatric Anxiety Inventory; GDS = Geriatric Depression Scale; FFMQ = Five Facet Mindfulness Questionnaire;

HAM-A: Hamilton Anxiety Scale; HAM-D: Hamilton Rating Scale for Depression; HAM-D17 = Hamilton Depression Rating Scale 17-item version; HAS = Hamilton Anxiety Scale; HDRS = Hamilton

Depression Rating Scale; K10 = Kessler Psychological Distress Scale; MASQ = Mood and Anxiety Symptoms Questionnaire; MINI = Mini Neuropsychiatric Interview; MRP = Mantram Repetition

Program; NRS 0-10 = Numeric rating scale for pain; ODI-I = Owestry low back pain disability questionnaire; PCL = PTSD Checklist; PCL-M = PTSD Checklist-Military; PC-PTSD = The Primary

Care PTSD Screen; PHQ = Patient Health Questionnaire; PSS = Perceived Stress Scale, QIDS = Quick Inventory of Depressive Symptomatology; QOLSV = Quality of Life Profile Seniors Version;

RSS = Ruminative Response Scale; SAI = Spielberger State Anxiety Inventory (SAI); SAS = Zung self-rating anxiety scale; SDS = Zung self-rating depression scale; SF-12 = Health Survey Short

Form-12; SPANE = Scale of Positive and Negative Experience; STAI = State-Trait Anxiety Inventory; WHOQoL-BREF = WHO Quality of Life-BREF


115

Evidence profile: Stand-alone mindfulness treatments

Authors (Year)

Design Total sample size


Number of treatment session, treatment duration, treatment frequency, group size




Mindfulness for PTSD

Group-based mindfulness for PTSD

Polusny, Erbes,

Thuras, Moran,

Lamberty,

Collins,

Rodman, Lim

(2015)

Clinical RCT N = 116 I = MBSR

(n = 58)

C = Present Centred

Group Therapy (PCGT)

(n = 58)

I = MBSR

- 8 weekly 2.5 h group sessions

- A daylong retreat, focused on

teaching participants to attend

to the present moment in a

non-judgemental, accepting

manner

C = PCGT


focused on current life

problems

USA

Veterans with PTSD diagnosis

according to DSM-IV or

subthreshold PTSD

Mean age:

MBSR = 57.6 [10.4]

PCGT = 59.4 [9.2]

Female gender:

MBSR = 21%

PCGT = 10%

PTSD symptom

severity:

- PCL

Diagnosis and

symptom severity of

PTSD:

- CAPS

Depressive symptom

severity:

- PHQ-9

Quality of life:

- WHOQoL-BREF

Mindfulness:

- FFMQ

This randomised clinical trial involving 116 veterans with PTSD compared the efficacy of MBSR to PCGT on PTSD symptom severity. Patients were recruited through advertisements and clinical

referrals at a large VA medical centre. Outcomes were assessed before, during, and after treatment and at 2-month follow-up. Participants receiving MBSR demonstrated greater improvement in self-

reported PTSD symptom severity during treatment (change in mean PCL scores from 63.6 to 55.7 vs 58.8 to 55.8 with present-centered group therapy; between-group difference = 4.95; 95% CI [1.92-

7.99]; p = 0.002) and at 2-month follow-up (change in mean PCL scores from 63.6 to 54.4 vs 58.8 to 56.0, respectively); between-group differences = 6.44; 95% CI [3.34-9.53], p <0.001). Although

participants in the MBSR group were more likely to show clinically significant improvement in self-reported PTSD symptom severity (49% vs 28% with present-centered group therapy; difference, 21%;

95%CI [2.2-39.5]; p = 0.03) at 2-month follow-up, they were no more likely to have loss of PTSD diagnosis (53% vs 47%, respectively; difference, 6.0%; 95%CI [14.1 - 26.2]; p = 0.55). For secondary

outcomes, the MBSR group showed significantly better outcomes in mindfulness (p <0.001) and quality of life (p = 0.004) at 2-month follow-up when compared to the PCGT group. There is a trend

toward significant difference for depression symptom severity between the two groups at 2-month follow-up (p = 0.06).

There was one serious adverse event in the PCGT group, in which a patient made a suicide attempt. Study limitations include that PCGT may not have fully accounted for all nonspecific factors present

in MBSR, with MBSR received longer total in-session time than the PCGT group.



116

Authors (Year)







Possemato,

Bergen-Cico,

Treatman,

Allen, Wade,

Pigeon (2016)

Clinical RCT N = 62 I = Primary Care Brief

Mindfulness Training

(PC-BMT) + Primary

Care Treatment as Usual

(PC-TAU)

(n = 36)

C = PC-TAU

(n = 26)

I = PC-BMT

- 4 weekly 1.5 h group sessions,

adapted from MBSR

- Provided with CDs with audio

files to support home practice,

which is a 2-minute Chill Out to

be used at least once daily for

all weeks

C = PC-TAU

Received usual PC treatment, could

include primary care mental health

integrated (PCMHI) care, including

medications and brief

psychotherapy provided by mental

health clinicians

USA

Veterans with subthreshold or

diagnostic-level PTSD according

to DSM-IV

Mean age:

PCBMT = 46.3 [16.4]

PC-TAU = 47.4 [16.2]

Female gender:

PCBMT = 17%

PC-TAU = 8%

PTSD Symptoms

severity:

- CAPS

- PCL-S

Depressive symptoms

severity:

- PHQ-9

This parallel, two-arm, single-blinded randomised clinical trial recruited 62 veterans from VA primary care clinics with subthreshold or diagnostic-level PTSD. This study tested whether a brief

mindfulness training (BMT) offered in primary care can decrease PTSD severity. PCBMT was adapted from manualised MBSR, and included much of the MBSR contents but with a shorter session

duration and fewer sessions overall. The outcomes were measured pre- and post- treatment using CAPS and PCL-S, and at 8-week follow-up using PCL-S. Intention-to-treat analysis results indicated

no statistical significance for differences in CAPS and PCL-S scores between PCBMT and PCTAU groups when followed up after 8 weeks. For the secondary outcomes, results indicated a significant

difference between PCBMT and PCTAU groups for depressive symptoms (p = 0.04), with PCBMT group showing a greater reduction in depressive symptom severity measured by PHQ-9.

Due to low participation rate in the PCBMT group (44.4% completed PCBMT, defined as completing at least three sessions), the study subsequently grouped the non-completers for PCBMT with the

PCTAU group and compared to the individuals who completed PCBMT. PTSD severity decreased in both groups, although the PCBMT completers reported significantly larger decreases in PTSD and

depression from pre- to post-treatment and maintained gains at the 8-week follow-up compared with the comparison group. Significant differences were observed in both CAPS and PCL-S measures

(p= 0.001 and p = 0.04 respectively).

No adverse event reported. Limitation of the study include a low rate of participant engagement in the PCBMT arm (44% completed PCBMT).

Individual mindfulness for PTSD


Mindfulness for depression


117

Authors (Year)







Group-based mindfulness for depression

Michalak,

Schultze,

Heidenreich,

Schramm

(2015)

Three-arm

clinical RCT

N = 106 I = MBCT

(n = 36)

C = Cognitive behavioural

analysis system of

psychotherapy (CBASP)

(n = 35)

C = TAU

(n = 35)

I = MBCT

- 1 individual pre-class interview


- Group size = 6

C = CBASP

- 2 individual treatment sessions


TAU = Patients were encouraged to

continue any current medication and

to attend appointments with their

psychiatrist or psychotherapist

Germany

Patients with a current major

depressive episode defined by

the DSM-IV and had

experienced depressive

symptoms for more than 2 years

without remission

Mean age:

MBCT +TAU = 48.4 [11.5]

CBASP + TAU = 50.2 [10.5]

TAU = 54.0 [13.24]

Female gender:

MBCT +TAU = 58%

CBASP + TAU = 63%

TAU = 66%

Depressive symptoms

severity:

- HAM-D

Depressive symptoms

severity:

- BDI

Quality of Life:

- SF-36

This was a bi-centre, three-arm randomised clinical trial, designed to evaluate the effects of MBCT compared to CBASP on depressive symptoms for patients with a current DSM-IV defined major

depressive episode and persistent depressive symptoms for more than 2 years. At Site A all patients were recruited by media announcements; at Site B patients were recruited from community health

care facilities or private practices. MBCT and CBASP groups were set up at each site, with four of each at Site A, and two of each at Site B. The group size was restricted to six patients per class in the

present trial in both treatment conditions.

The pre- and post-assessment results indicated that MBCT was no more effective than TAU in reducing depressive symptoms (p = 0.76) at Site A, although it was significantly superior to TAU at

treatment Site B (p = 0.01).

CBASP was significantly more effective than TAU in reducing depressive symptoms in the overall sample and at both treatment sites (Ps <0.01). Overall, the direct comparison of MBCT and CBASP in

terms of changes in depression scores at post-treatment did not reveal any statistical significance for a difference between the two groups. Similarly for remission rates, no significant difference between

MBCT and CBASP groups was observed. Both treatments had only small to medium effects on social functioning and quality of life.

No adverse events were reported. There was no follow-up data for the studies and therefore long-term outcomes cannot to be determined.

Shallcross,

Gross,

Visvanathan,

Kumar, Palfrey,

RCT N = 92 I = MBCT

(n = 46)

I = MBCT


USA

Participants with confirmed

MDD-related and co-morbid Axis

Relapse and time to

relapse for depression:

- SCID

Depressive symptoms

severity:

- BDI


118

Authors (Year)







Ford, Dimidjian,

Shirk, Holm-

Denoma,

Goode, Cox,

Chaplin, Mauss

(2015)

C = Active control (AC)

(n = 46)

- Outside of class for homework

(approximately 50 minutes per

day)

- Group size = 10-12

C = AC was based on the validated

and manualised Health

Enhancement Program (HEP)


- Outside of class for homework

(approximately 50 minutes per

day)

- Group size = 10-12

I/II diagnostic eligibility based on

Clinical Interview for the DSM-IV

(SCID I/II)

Mean age:

MBCT = 36.7 [12.8]

AC = 33 [9.6]

Female gender:

MBCT = 76%

ACC = 76%

Life satisfaction:

- SWL

This RCT evaluated the comparative effectiveness of MBCT versus an active comparison condition for depression relapse prevention, depressive symptom reduction and improvement in life

satisfaction. Participants were recruited from an urban area through referrals from community mental health centres and local advertisements.

Intention-to-treat analyses indicated no differences between MBCT and AC in depression relapse rates (OR = 1.10, 95% CI [0.42-2.92], p = 1) or time to relapse over a 60-week follow-up using a

survival analysis (HR = 0.945, 95% CI [0.36-2.45], p = 0.91). Both groups experienced significant and equal reductions in depressive symptoms and improvements in life satisfaction. The AC group

experienced immediate symptom reduction post-intervention and then a gradual increase over the 60-week follow-up. The MBCT group experienced a gradual linear depression symptom reduction. The

pattern for life satisfaction was identical but only marginally significantly different to each other.

Limitations of the study include small effect sizes for analyses and therefore only confer modest statistical power. There was also a high level of drop-outs in both groups which can introduce attrition

bias.

Williams,

Crane,

Barnhofer,

Brennan,

Duggan,

Fennell, et al.

(2014)

Three-arm

RCT

N = 274 I = MBCT

(n = 108)

C = cognitive

psychological education

(CPE)

(n = 110)

C = TAU

(n = 56)

I = MBCT

- 1 individual Pre-class interview

- 8 weekly 2 h classes

- Participants were invited to 2h

follow-up classes taking place

6 weeks and 6 months post-

treatment

- Each follow-up class included

meditation, discussion of

discoveries and difficulties

UK

Patient with a history of at least

three episodes of major

depression meeting DSM–IV

Mean age:

MBCT = 43.99 [11.55]

CPE = 43.86 [12.92]

TAU = 43.43 [12.03]

Time until relapse to

major depression:

- SCID criteria for

at least 2 weeks

since the previous

assessment

Depression symptom

severity:

- HAM-D


119

Authors (Year)







since the course ended, and

how these were being dealt

with by participants

C = CPE comprised all elements of

the MBCT program except the

experiential cultivation of

mindfulness through meditation

practice

- 8 weekly 2 h classes

- Follow-up classes at 6 weeks

and 6 months

C = TAU = Receive treatment as

usual, with 21% received on or more

new antidepressants prescriptions,

11% saw psychiatrist or community

psychiatric nurse, 21% saw

counsellor, psychologist or

psychotherapist during follow-up

Female gender:

MBCT = 71%

CPE = 74%

TAU = 70%

- BDI

This RCT compared mindfulness-based cognitive therapy (MBCT) with both cognitive psychological education (CPE) and treatment as usual (TAU) for preventing relapse to major depressive disorder

(MDD) in people currently in remission following at least 3 previous episodes. Participants recruited through referrals from primary care and mental health clinics and advertisements in the community.

Participants were allocated to MBCT plus TAU, CPE plus TAU, and TAU alone. MBCT was delivered in accordance with its published manual, modified to address suicidal cognitions; CPE was

modelled on MBCT, but without training in meditation. Both treatments were delivered through 8 weekly classes.

Follow-up measurements took place at 3, 6, 9, 12 months after randomisation. Allocated treatment had no significant effect on risk of relapse to MDD over 12 months follow-up (hazard ratio for MBCT

vs. CPE = 0.88, 95% CI [0.58, 1.35]). Among participants above median severity, the hazard ratio was 0.61, 95% CI [0.34, 1.09], for MBCT vs. CPE. For those below median severity, there were no

such differences between treatment groups.

Fifteen serious adverse events were reported to the research team, with five arising from MBCT and 10 from CPE. Only one of these serious adverse reaction was potentially arising from a trial

treatment – an episode of serious suicidal ideation following discussion of different coping responses to low mood in CPE. Others involved an overnight hospital admission, with 13 for physical health

problems and 1 following an overdose during follow-up in a patient received MBCT. One participant died from an unrelated medical condition after partially withdrawing from trial follow-up due to illness.

A limitation of the study includes data being analysed ‘as treated’. This can introduce bias associated with the non-random loss of participants (i.e,. attrition).

Individual mindfulness interventions for depression


120

Authors (Year)







Tovote, Fleer,

Snippe,

Peeters,

Emmelkamp,

Sanderman,

Links,

Schroevers

(2014)

RCT N = 94 I = Individual MBCT

(n = 31)

C = CBT

(n = 32)

C = Waitlist (WL)

(n = 31)

I = MBCT

- Delivered individually

- 8 weekly sessions

- Each session lasts for 45-60

minutes

- Daily 30 minutes homework

C = CBT

- Delivered individually

- 8 weekly sessions

- Each session lasts for 45-60

minutes

- Daily 30 minutes homework

C = WL

Participants in the WL condition

received no psychological

intervention for 3 months.

The Netherlands

Participants were adult patients

with type I or II diabetes

diagnosed at least 3 months

prior to inclusion, and having

symptoms of depression as

indicated by a Beck Depression

Inventory-II (BDI-II) score of ≥14

Mean age:

MBCT = 49.8 [13.3]

CBT = 54.6 [11.3]

WL = 54.7 [10.5]

Female Gender:

MBCT = 55%

CBT = 50%

WL = 48%

Depressive symptom

severity:

- BDI-II

- HAM-D7

Wellbeing:

- WHO-5

Anxiety symptom

severity:

- GAD-7

This RCT from the Netherlands examined the effectiveness of individual MBCT and CBT for depressive symptoms in patients with diabetes in comparison with a waitlist condition. Patients were

recruited from four hospitals in the northern part of Netherlands.

The pre-post treatment results for primary outcome on depression showed that both MBCT and CBT had significantly decreased BDI-II scores than the WL group at post-treatment (p = 0.004 and p

<0.001, respectively). However, when compared between MBCT and CBT groups directly, no significant differences were observed. Assessing depressive symptoms using the HAM-D7 revealed similar

results: both MBCT and CBT had significantly higher outcome improvement than WL condition (p <0.001 and p = 0.001, respectively). For secondary outcomes, comparing MBCT and CBT groups with

the WL group, individuals in both MBCT and CBT exhibited greater improvement in levels of wellbeing (both Ps <0.001) and anxiety symptom severity (p = 0.004 and p = 0.01, respectively).

No adverse event reported. Several limitations to this study including a smaller sample size limiting the statistical power. Secondly, attrition rates in both MBCT and CBT were high, as only around 70%

of the randomized participants completed treatment. In addition, the study sample is a group of patients diagnosed with diabetes comorbid with depression, hence the results may not be generalisable

to all types of depression.

Mindfulness for anxiety


121

Authors (Year)







Group-based mindfulness for anxiety

Arch, Ayers,

Baker, Almklov,

Dean, Craske

(2013)

RCT N = 124

I = MBSR

(n = 45)

C = CBT

(n = 60)

I = MBSR

- 10 weekly 1.5 h group

sessions

- One 3 h onsite mindfulness

retreat in week 7 served as the

treatment session of that week

C = Group-based CBT


sessions

USA

Veterans satisfy the DSM-IV

diagnosis of heterogeneous

anxiety disorders including panic

disorder with or without

agoraphobia (PD/A), generalized

anxiety disorder (GAD), social

anxiety disorder (SAD), specific

phobia (SP), obsessive-

compulsive disorder (OCD) or

civilian posttraumatic stress

disorder (PTSD)

Mean age:

MBSR = 46.48 [14.45]

CBT = 45.50 [13.21]

Female gender:

MBSR = 21%

CBT = 14%

Anxiety disorder

diagnosis:

- PSWQ-16

- Principal CSR

Depressive symptoms

severity:

- BDI-II

Arousal symptoms:

- MASQ-Anxious

Arousal

This randomised controlled trial compared an adapted mindfulness-based stress reduction with cognitive behavioural therapy for the group treatment of 105 veterans with one or more anxiety disorders

(PD, GAD, SAD, PTSD, SP and OCD). Veterans were recruited from an outpatient VA Healthcare System Medical Centre specialise in treatment of anxiety disorders.

The results indicate both groups showed large and equivalent improvements on principal disorder severity through 3-month follow up (p <0.001, d = -4.08 for adapted MBSR; d = -3.52 for CBT). For

anxious arousal outcomes at follow up, CBGT group showed better performance than the MBSR group (p <0.01, d = 0.49), whereas adapted MBSR reduced worry at a greater rate than CBGT (p <0.05,

d = 0.64). For the secondary outcome, no between-group difference for depressive symptoms were observed at a statistically significant level.

No adverse effects were reported. The study recruited a particularly complex patient population which meant that attrition rates were high, and only about half of patients completed an adequate dose of

treatment (defined as 70% or 10.5h). The sample size is respectable, but somewhat underpowered to detect group differences of medium effect size, and this was exacerbated by attrition. In addition,

the sample is relatively diverse, consisting of patients suffering from a spectrum of anxiety disorders, which represents a limitation to distinguishing the effects on a specific disorder.

Goldin,

Morrison,

Jazaieri,

Three-arm

RCT

N = 108

I = MBSR

(n = 36)

I = MBSR

- 12 weekly 2.5 h sessions

USA Social anxiety

symptoms severity:

N/R


122

Authors (Year)







Brozovich,

Heimberg,

Gross (2016)

C = Cognitive-based

group therapy (CBGT)

(n = 36)

C = WL

(n = 36)

- Modified so that the 1-day

meditation retreat was

converted to four additional

weekly group sessions

between the standard Class 6

and 7

C = CBGT was delivered by two

doctoral clinical psychologists

- 12 sessions of 2.5 h each (total

time= 30 h)

- Groups size = 6

Patients met DSM-IV-TR criteria

for a principal diagnosis of

generalised SAD

Mean age:

CBGT = 34.1 [8.0]

MBSR = 29.9 [7.6]

WL = 34.1 [7.8]

Female gender:

CBGT = 56%

MBSR = 56%

WL = 56%

- LSAS-SR

This randomised controlled trial investigated treatment outcomes for cognitive behavioural group therapy (CGGT) versus mindfulness-based stress reduction (MBSR) versus WL in patients with

generalised social anxiety disorder (SAD). Patients were recruited through clinician referrals and community listings. Unmedicated patients (N = 108) meeting DSM-IV-TR criteria for a principal

diagnosis of generalised SAD were included, and subsequently randomised to CBGT, MBSR or WL. Assessments were completed at baseline, post-treatment/WL, and at 1-year follow-up.

Both CBGT and MBSR yielded improvements in social anxiety symptoms (p <0.001), with greatest reduction of social anxiety symptoms measured by LSAS-SR observed in the CBGT group, with 48%

change from baseline level. The MBSR group showed 40% reduction of social anxiety symptoms from baseline. However, there was no significant difference for CBGT versus MBSR (p = 0.18),

indicating similar treatment efficacy. In addition, the study looked at whether there was equivalent maintenance of reduced social anxiety symptoms from immediately after treatment to 1-year post

treatment. Results indicated no significant differences (p = 0.11), suggesting similar sustained clinical improvement during the 1-year follow-up period between CBGT and MBSR groups.

No adverse events were reported. Dropout from treatment was low and did not differ between the three arms (CBGT: 6%; MBSR: 8%; WL: 3%). Limitations included self-reported measures which can

introduce reporting bias.

Hoge, Bui,

Marques,

Metcalf, Morris,

Robinaugh,

Worthington,

Pollack, Simon

(2013)

RCT N = 93

I = MBSR

(n = 48)

C = Stress Management

Education (SME)

(n = 45)

All participants were given the ‘Trier

Social Stress Test’ before and at the

end of the trial. TSST consists of an

8-minute public speaking task and a

subsequent 5-minute mental

arithmetic task (serial subtraction)

performed in front of two strangers

I = MBSR

- 8 weekly 2 h group classes

USA

Patients with DSM-IV criteria for

current primary GAD and

designated GAD as the primary

problem

Mean age:

MBSR = 41 [14]

SME = 37 [12]

Female gender:

Anxiety symptoms

severity:

- HAM-A

- CGI-S & CGI-I

- BAI

Stress reactivity:

- STAI


123

Authors (Year)







- A single 4 h weekend ‘retreat’

day

- Daily 20 minutes home

practice guided by audio

recordings

C = SME course was designed as

an active control, for comparison

with MBSR, and did not contain any

mindfulness components

- 8 weekly 2 h group classes

- A single 4 h weekend “Special

Class”

- Daily 20 minutes home

practice guided by audio

recordings

MBSR = 48%

SME = 54%

This randomised controlled trial compared the manualised Mindfulness-Based Stress Reduction (MBSR) program with Stress Management Education in 93 patients with a diagnosis for GAD based on

DSM-IV. Anxiety symptoms were measured with the Hamilton Anxiety Scale (HAM-A, primary outcome measure), the Clinical Global Impression of Severity and Improvement (CGI-S and CGI-I), and

the Beck Anxiety Inventory (BAI). Stress reactivity was assessed by comparing anxiety and distress during pre- and post-treatment Trier Social Stress Tests (TSST). Participants were recruited by

referral and media advertisement.

A modified intent-to-treat analysis including participants who completed at least one session of MBSR (N = 48) or SME (N = 41) showed that both interventions led to significant reductions in HAM-A

scores at endpoint (p <0.0001), but did not significantly differ from each other. MBSR, however, was associated with a significantly greater reduction in anxiety as measured by the CGI-S, the CGI-I, and

the BAI (all Ps <0.05). MBSR was also associated with greater reductions than SME in anxiety and distress ratings in response to the TSST stress challenge (P <0.05), and a greater increase in positive

self-statements (P = 0.004).

One participant in the MBSR group reported muscle soreness and one participant in the SME group reported sleep disruption as adverse events.

Kocovski,

Fleming,

Hawley, Huta,

Antony (2013)

RCT N = 137

I = mindfulness and

acceptance-based group

therapy (MAGT)

(n = 53)

C = cognitive behavioural

group therapy (CBGT)

(n = 53)

I = MAGT

- 7 sessions, each starting with a

mindfulness exercise (lasting

approx. 15 minutes) followed

by inquiry

- Homework was reviewed after

the mindfulness exercise and

Canada

Patients with a principal

diagnosis of SAD, Generalised

using DSM-IV-TR

Mean age:

Social anxiety

symptom severity:

- SPIN

- LSAS

Depressive symptoms

severity:

- BDI

Mindfulness:

- FMI


124

Authors (Year)







C = WL

(n = 31)

consisted of mindfulness

exercises

C = CBGT

- First two sessions in CBGT

focused on an introduction to

the CBT model and cognitive

restructuring

- Sessions 3 to 11 focused on

in-session exposures (using an

extinction rationale) with

cognitive restructuring prior to

each exposure and cognitive

debriefing afterwards

- Homework, consisting of

exposures and cognitive

restructuring, was reviewed

and set each week

In both CBGT and MAGT, session

12 and the briefer follow-up session

focused on review and planning

MAGT = 34.94 [12.52]

CBGT = 32.66 [9.07]

WL = 36.55 [11.58]

Female gender:

MAGT = 49 %

CBGT = 53%

WL = 65%

This randomised controlled trial compared mindfulness and acceptance-based group therapy (MAGT) with cognitive behavioural group therapy (CBGT) in a group of individuals diagnosed with SAD.

Participants were recruited via advertisements in local Newspapers, letters sent to physicians informing them of the study, and flyers posted in clinics and other public places.

The primary outcome was social anxiety symptom severity assessed at baseline, treatment midpoint, treatment completion, and 3-month follow-up. MAGT and CBGT were both more effective than the

WL group (p <0.001) but did not significantly differ from one another on social anxiety reduction and most other variables assessed.

No adverse effects were reported. Dropout rate was high (include percentage/rate of dropout) and commonly the reason for exiting the study was time commitment. Much of the data presented in the

study relied on self-report, and therefore increased the risk of reporting bias. There was significant attrition (30% for MAGT, 40% for CBGT), and the follow-up data may have been particularly affected

by attrition bias with only around half of patients providing follow-up data.

Wong, Yip,

Mak, Mercer,

Cheung, Ling,

Lui, Tang, Lo,

Wu, Lee, Gao,

Three-arm

RCT

N = 182 I = MBCT

(n = 61)

C = Psychoeducation

(n = 61)

I = MBCT

- 8 weekly 2 h group session

- Modification included

discussing the cognitive-

Hong Kong

Patients with a DSM-IV principal

diagnosis of GAD on a SCID

and a score of 19 or above using

Anxiety symptoms

severity:

- BAI (Chinese

version)

Depressive symptoms

severity:

- CES-D (Chinese

version)


125

Authors (Year)







Griffiths, Chan,

Ma (2016)

C = TAU

(n = 60)

behavioural model of GAD,

automatic anxiety thoughts,

reactive–avoidance and

ruminative worrying and the

development of an action plan

in line with personal values and

relapse prevention of anxiety

- Group size = 15

C = Psychoeducation

- 8 weekly 2 h group session

- With didactic teaching and

minimal group interaction and

discussion

- Group size = 15

C = TAU

Participants did not receive any

specific intervention but allowed

unrestricted access to primary care

services

the Chinese version of BAI at

baseline

Mean age:

MBCT = 50.40 [9.95]

Psychoeducation = 50.79 [9.57]

TAU = 48.78 [10.59]

Female gender:

MBCT = 79%

Psychoeducation = 79%

TAU = 80%

Health-related

quality of life:

- MCS-12

- PCS-12

This RCT compared changes in anxiety levels among participants with GAD who were randomly assigned to MBCT, cognitive-behavioural therapy-based psychoeducation and usual care. Participants

with GAD were assigned to the three groups and followed for 5 months after baseline assessment with the two intervention groups followed for an additional 6 months. Primary outcomes were anxiety

levels. All participants were recruited from: (a) advertisements placed in the health education columns of local newspapers; (b) public general practice or family medicine clinics; and (c) non-

governmental organisations and community centres that cater for people with chronic conditions.

The results from BAI indicated significant decreases from baseline in both MBCT and psychoeducation groups at both 2-months and 5-months follow-up (F (4,148) = 5.10, p = 0.001), but no significant

relative change between MBCT and Psychoeducation groups. For secondary outcomes, significant group differences were seen for CES-D and MCS-12 scales between the psychoeducation and usual

care groups at 2- and 5-months after baseline assessment. No significant group differences were observed between the MBCT and TAU groups or the MBCT and psychoeducation groups at these time

points. In addition, no significant group differences in these outcomes between MBCT and psychoeducation groups at 8 and 11 months.

Limitations include much lower adherence for MBCT group than the psychoeducation group. The outcome measures were based on self-reported questionnaires, and no clinician-rated instruments or

diagnostic interviews were used at follow-up. As a result, it is unknown whether the improvements in anxiety symptoms led to clinical remission of GAD. In addition, participants had at least moderate

levels of generalised anxiety symptoms at the time of recruitment based on validated self-reported questionnaires, and the majority of the participants were recruited via advertisements. As a result, the


126

Authors (Year)







results may not be generalisable to patients who experience a milder degree of anxiety symptoms or to all patients in clinical settings. There may also have been a selection bias of recruited participants

being more motivated when compared with those patients seen in clinics.

Individual mindfulness for anxiety


Mindfulness for combined depression and anxiety

Group-based mindfulness for combined depression and anxiety

Sundquist, Lilja,

Palmer,

Memon, Wang,

Johansson,

Sundquist

(2015)

RCT N = 215

I = Mindfulness group

therapy

(n = 110)

C = TAU =

Pharmacological

treatment and

psychotherapy or

counselling

(76% of control received

CBT)

(n = 105)

I = Mindfulness group therapy, a

combination of MBSR and MBCT

- 8 weekly 2 h group sessions

- Home mindfulness practice for

20 min/day using a compact

disc, a training manual and a

diary

C = The control group received

TAU, which sometimes included

pharmacological treatment and in

most cases also psychotherapy or

counselling. 76% of patients in the

control group received CBT. The

average number of individual CBT

sessions was six

Sweden

Patients newly diagnosed with

psychiatric disorders based on

ICD-10 diagnostic criteria or

those who had a history of

psychiatric disorders who sought

treatment

Mean age:

Mindfulness = 42 [11]

TAU = 41 [11]

Female gender:

Mindfulness = 81%

TAU = 90%

Depressive symptoms

severity:

- MADRS-S

- HADS-D

- PHQ-9

Anxiety symptoms

severity:

- HADS-A

N/R

This study explored the efficacy of MBCT versus TAU (mostly individual CBT) in terms of reducing depression and anxiety symptoms. The sample was heterogeneous, consisting of 215 individuals

suffering from depression, anxiety, stress and adjustment disorders recruited from 16 primary care clinics in South Sweden. Comparing pre- and post-treatment data, both MBCT and TAU groups

exhibited significant reduction in depression and anxiety symptom severity (p<0.001), however, the results did not significantly differ from each other between groups (MDRS-S: OR = 1.04, 95% CI

[0.49-2.22], p = 0.92; HADS-D: OR = 0.59, 95% CI [0.28-1.25], p = 0.17; HADS-A: OR = 0.83, 95% CI [0.39-1.75], p = 0.62; PHQ-9: OR = 0.75, 95% CI [0.35-1.59], p = 0.45).

No adverse events were reported. Limitations included that all measures were self-report measures, which introduced a risk of reporting bias. The study sample was a very heterogeneous group with a

mix of patients with depression, anxiety, stress and adjustment disorders, and therefore it was difficult to determine the effect of the mindfulness intervention on specific types of disorder.


127

Authors (Year)







Individual mindfulness for combined depression and anxiety


Mindfulness for AUD

Group-based mindfulness for AUD

Garland,

Roberts-Lewis,

Tronnier,

Graves, Kelley

(2016)

Three-arm

RCT

N = 180 I = Mindfulness-Oriented

Recovery Enhancement

(MORE)

(n = 64)

C = CBT

(n = 64)

C = TAU

(n = 52)

I = MORE

- 10 session adapted as a

treatment for alcohol

dependence from MBCT

- 15 minutes per day

C = CBT

- 10 group 2 h sessions

- Participants were asked to do

daily homework

C = TAU

- TAU in the modified

therapeutic community

consisted of: participation in a

therapeutic milieu

- psychoeducation on topics

related to addiction; client-

centred, supportive-expressive

group therapy and coping skills

group

USA

Patients with co-occurring

substance use and psychiatric

disorders, defined by the DSM-

IV

Mean age:

MORE = 37.7 [10.4]

CBT = 36.5 [11.2]

TAU = 38.7 [9.8]

Female gender:

0%

Alcohol craving:

- PACS

PTSD symptoms

severity:

- 17-item PTSD

Checklist-Civilian

version (PCL-C)

Depression and

anxiety severity:

- Subscales of BSI

This randomised controlled trial consisted of three arms, compared Mindfulness-Oriented Recovery Enhancement (MORE) to group-based Cognitive-Behavioural Therapy (CBT) and TAU. The study

participants were recruited from a modified therapeutic community in an urban area. Men with co-occurring substance use and psychiatric disorders, as well as extensive trauma histories were included.

In the study sample, 47% of the participants had alcohol dependence.


128

Authors (Year)







The study results indicated improvements in substance craving (p = 0.03), post-traumatic stress (p = 0.04), and negative affect (p = 0.04) in the MORE group when compared to CBT; however,

depression and anxiety outcome measures using BSI did not exhibit any statistical significance between the two groups.

Limitations included a lack of biochemical measures of abstinence, these types of measures may be better at measuring abstinence than self-report measures, which may increase the risk of reporting

bias. Another limitation was that less than half of the sample had alcohol dependence, therefore the effects of mindfulness on treating AUD specifically cannot be determined.

Garland,

Gaylord,

Boettiger,

Howard (2010)

RCT N = 53 I = MORE

(n = 27)

C = Alcohol Support

Group (ASG)

(n = 26)

I = MORE

- 10 session adapted as a

treatment for alcohol

dependence from MBCT

- 15 minutes per day

C = ASG

- 10 session consisted of social

support groups derived from

the active, evidence-based

treatment condition outlined in

the Matrix Model intensive

outpatient treatment manual

USA

Patients who met lifetime DSM-

IV for alcohol dependence

Mean age:

MORE = 39.9 [8.7]

ASG = 40.7 [10.2]

Female Gender:

MORE = 19%

ASG = 23%

Psychosocial factors

related to alcohol

dependence:

- BSI

- IRISA

- WBSI

Stress:

- PSS-10

Mindfulness:

- FFMQ

This randomised controlled trial recruited 53 alcohol-dependent adults recruited from a modified therapeutic community in an urban area. The study participants were randomised to mindfulness training

(MORE) or a support group (ASG). 37 participants completed the interventions.

Outcome measures were taken before the intervention and 10 weeks post-intervention. The results indicated both MORE and ASG led to significant reductions in perceived stress over time (F (1, 35) =

18.11, p <0.001). MORE led to significantly larger decreases in perceived stress (mean difference = 3.3, 95% CI [3.09- 3.51], p = 0.03) and thought suppression (mean difference = 6.1, 95% CI [5.77-

6.43], p = 0.04) over the 10-week period than ASG. The results also indicated increased physiological recovery from alcohol cues, and modulated alcohol attentional bias among the MORE participants.

Limitations of the study included a small sample size which therefore limited the statistical power and generalisability. Another notable limitation was that self-report measures were administered through

face-to-face interviews, which may have led to social desirability bias in self-reported outcomes.

Zgierska,

Shapiro,

Burzinski,

Lerner,

Goodman-

Strenski (2017)

Parallel

RCT

N = 123 I = Mindfulness-Based

Relapse Prevention for

Alcohol (MBRP-A)

(n = 64)

C = TAU

(n = 59)

I = MBRP-A

- 8 weekly, therapist-led,

manual-driven 2 h group

sessions


practice Mindfulness

USA

Adult patients with a SCID-

confirmed diagnosis of alcohol

dependence in an early

remission

Mean age:

Alcohol problem:

- Self-reported

helpfulness of the

program for

alcohol problem

N/R


129

Authors (Year)







Meditation at home throughout

the 26-week study

C = TAU=Typically included

motivational enhancement,

relapse prevention, and 12-step

facilitation strategies

41.2 [11.9]

Female gender:

43%

This parallel randomised controlled trial investigated the effectiveness of a mindfulness-based relapse prevention for alcohol intervention compared to TAU on self-report alcohol problem severity in 123

alcohol dependent adults. Participants were alcohol dependent adults in early recovery recruited from eight local addiction treatment centres. The participants were randomised into receiving either

MBRP-A, or continued their treatment as usual, which typically include motivational enhancement, relapse prevention, and 12-step facilitation strategies. Overall change in alcohol problem at the 8-week

follow-up in the intervention group reported a mean score of 5.8 [SD=0.9] (On a 1-7 Likert Scale, with 1=very much worse, 7=very much improved), indicating that their “alcohol problem” improved since

their study enrolment and rating the intervention as helpful for their “alcohol problem” (1.7 [SD=0.7]; 1-5 Likert scale, with 1=very helpful, 5=not helpful and has made things worse).

No comparison was made to the TAU comparison group. In addition, the outcome measure has not been validated in other studies, and the outcomes were not based on clinical assessments.

Individual mindfulness for AUD


N.B:

BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; BSI = Brief Symptom Inventory; CAPS = Clinician-Administered PTSD Scale; CEDS = the Center for Epidemiologic Studies

Depression Scale; CGI-S = Clinical Global Impression of Severity and Improvement; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders 4th Edition; FMI = 14-item Freiburg Mindfulness

Inventory; GAD-7 = Generalized Anxiety Disorder-7 scale; HAM-A = Hamilton Anxiety Rating Scale; HAM-D17 = 17-item Hamilton Depression Rating Scale; IRISA = Impaired Alcohol Response

Inhibition Scale; LSAS = 24-item Liebowitz Social Anxiety Scale; mADM = maintenance antidepressant medication; MBCT = Mindfulness-Based Cognitive Therapy; MBSR = Mindfulness-Based

Stress Reduction; MCS-12 = the Mental Component Summary; N/A = Not Available; N/R = Not Reported; PACS = Penn Alcohol Craving Scale; PCGT = Present Centred group therapy; PCL =

PTSD Checklist; PCL-C = PTSD Checklist – Civilian; PCL-M = PTSD Checklist – Military; PCL-S = PTSD Checklist - Specific; PCS-12 = Physical Component Summary; PHQ = Patient Health

Questionnaire; PSS-10 = The 10-item Perceived Stress Scale; PSWQ = Penn State Worry Questionnaire; SCID = Structured Clinical Interview for DSM-IV; SCL-90 = Symptom Distress Checklist;

SF-36 = Short Form Health Survey 36-item; SPIN = Social Phobia Inventory; STAI = State-Trait Anxiety Inventory; TAU = Treatment as Usual; TSST = Trier Social Stress Tests; QOLI = Quality of

Life Inventory; WBSI = White Bear Suppression Inventory; WHO-5 = The Well-Being Index; WHOQoL-BREF = World Health Organization Quality of Life –BREF


130

Evidence profile: Adjunct meditation, yoga and mindfulness treatments

Authors & year







ADJUNCT MEDITATION AND TRANSCENDENTAL MEDITATION

Adjunct meditation for PTSD


Adjunct meditation for depression


Adjunct meditation for anxiety


Adjunct meditation for AUD


ADJUNCT YOGA

Adjunct group yoga for PTSD (compared to active comparison)

van der Kolk,

Stone, West,

Rhodes,

Emerson,

Suvak, &

RCT N = 64 I = Trauma-informed yoga

+ psychopharmacologic

treatment (supportive

therapy, pharmacologic

treatment)

(n = 32)

I = Protocolised trauma-informed

yoga intervention incorporating

the central elements of Hatha

yoga including breathing, posture

and meditation

USA

Women with chronic,

treatment-resistant PTSD

based on CAPS score (if

greater than 45). Chronicity

was based on meeting criteria

PTSD symptom severity:

- CAPS

- DTS

Depressive symptom

severity:

- BDI-II



131

Authors & year







Spinazzola

(2014)

C = Supportive women’s

health education +

Psychopharmacologic

treatment (supportive

therapy, pharmacologic

treatment)

(n = 32)

- 10 weekly 1 hr group

classes

C = Women’s health education

focused on active participation

and support

- 10 weekly 1 hr group

classes

for PTSD in relation to an

index trauma that occurred at

least 12 years prior to intake.

Mean age:

Yoga = 41.5 [12.2]

Control = 44.3 [11.9]

Female gender:

100%

This study assessed the efficacy of trauma-informed yoga adjunct to psychopharmacologic treatment versus supportive women’s health education adjunct to psychopharmacologic treatment on chronic,

treatment-resistant PTSD in women. The participants were recruited via newspaper and radio ads, website, and solicitation from mental health professionals. The study randomly assigned 64 women with

chronic, treatment-resistant PTSD to receiving trauma-informed yoga or supportive women’s health education interventions, with primary outcome of interest being change in PTSD symptom severity

measured by CAPS. Depressive symptom severity measured by BDI-II were secondary outcomes in this study.

Assessments were conducted at pre-treatment, mid-treatment and post-treatment. For primary outcome measure, both groups exhibited significant decreases on the CAPS score, with the decrease falling

in the large effect size range for the yoga group (d = 1.07) and the medium to large effect size decrease for the comparison group (d = 0.66). Both groups exhibited significant decrease in PTSD symptoms

measured by DTS during the first half of the treatment from pre-treatment to mid-treatment assessment (yoga: p = 0.02; d = -0.37, comparison: p = 0.001; d = -0.54), with the improvements maintained in

the yoga group, while the comparison group relapsed after its initial improvement. For secondary outcome, the BDI-II scores decreased significantly in both groups, with the yoga group showing a medium

effect size decrease (d = -0.60) and the comparison condition exhibiting a small to medium effect size decrease (d = -0.39). However, the differences between the two groups were not statistically

significant.

No adverse events were reported. The study sample consisted only of treatment-resistant adult women with chronic PTSD secondary to interpersonal assaults that started in childhood, limiting the

generalisability of findings.

Adjunct individual yoga for PTSD


Adjunct group yoga for depression (compared to active comparison)

Sarubin,

Nothdurfter,

Schule, Lieb,

Uhr, Born et al.

(2014)

RCT N = 53 I = Hatha Yoga + atypical

antipsychotic drug with

antidepressant properties

(Quetiapine fumarate

extended release (QXR)

I = Hatha yoga + antipsychotic

drug

- 5 weeks with either QXR

(300mg/day) or ESC

Germany

In-patients suffering from

MDD according to DSM-IV

Mean age:

Depressive symptom

severity:

- 21-HAMD

N/R


132

Authors & year







or Escitalopram (ESC))

(n = 22)

C = Atypical antipsychotic

drug with antidepressant

properties only

(Quetiapine fumarate

extended release (QXR)

or Escitalopram (ESC))

(n = 31)

(10mg/day) plus Hatha yoga

(60 min/week)

- Maximum group size = 15

C = antipsychotic drug only

- 5 weeks with either QXR

(300mg/day) or ESC

(10mg/day)

Yoga = 37.27 [11.85]

Control = 42.36 [12.85]

Female gender:

Yoga = 36%

Control = 23%

This RCT evaluated the effectiveness of Hatha yoga as an add-on treatment to atypical antipsychotic drugs in a group of patients suffering from MDD. In-patients suffering from MDD (n = 53) were

randomised to a 5-week treatment with yoga in addition to their medication (either QXR or ESC) or continuing their medication only without receiving any yoga intervention. The 21-HAMD was used weekly

to measure the change in depressive symptom severity.

There were no baseline differences between the two groups for 21-HAMD total score (p=0.46). A statistically significant reduction in depressive symptoms as measured by 21-HAMD after five weeks of

treatment compared to baseline was observed in both groups. When comparing the two groups at follow-up, there was no statistically significant group effect (F=0.003; p=0.935).

No adverse events were reported. The study was limited by a small sample size and an unequal number of participants in the intervention and comparison arms.

Sharma, Barrett,

Cucchiara,

Gooneratne, &

Thase (2017)

Randomised

pilot study

N = 25 I = Sudarshan Kriya Yoga

(SKY) + antidepressant

(n = 13)

C = WL + antidepressant

(n = 12)

I = The SKY yoga intervention

consisted of two phases of a

manualised, group program

featuring a breathing-based

meditative technique. SKY

includes a series of sequential,

rhythm-specific breathing

exercises that bring practitioners

into a restful, meditative state.

- During the first phase,

participants need to

complete six-session SKY

program for 3.5 hours per

day

- During the second phase,

participants attended weekly

USA

Outpatients with MDD

(defined by DSM-IV-TR), with

≥8 weeks of stable dose of

antidepressant treatment and

total scores ≥14 on the

HDRS-17

Mean age:

SKY = 39.4 [13.9]

WL = 34.8 [13.6]

Female gender:

SKY = 69%

WL = 75%

Depressive symptom

severity:

- HDRS-17

Depressive symptom

severity:

- BDI

Anxiety symptom severity:

- BAI


133

Authors & year







SKY follow-up sessions for

1.5 hours per session

- Participants were also asked

to complete a home practice

version of SKY (20-25

minutes per day)

C = Participants maintained their

antidepressant dose and were

offered the yoga intervention after

completing the study

A randomised pilot study evaluated the efficacy of Sudarshan Kriya Yoga (SKY) as an adjunct intervention in patients with major depressive disorder (MDD). Outpatient with MDD (defined by DSM-IV-TR)

despite ≥8 weeks of antidepressant treatment were randomized to SKY or a WL (delayed yoga) arm for 8 weeks.

Results from the ITT sample (N=25), indicated that the SKY group showed a greater improvement in HDRS-17 total score compared to the WL from baseline to 2 months follow-up (-9.77 vs 0.50, p =

0.0032). For secondary outcomes, the SKY group also showed greater reduction in BDI total score compared to the waitlist condition at 2 months follow-up (-17.23 v.s. -1.75, p = 0.0101). In addition, mean

changes in BAI total score were significantly greater for SKY than waitlist at 2-months follow-up (-5.19, 95% CI -9.34 to -0.93, p = 0.0097).

No adverse events were reported. The statistical power of the study was limited by a small sample size. The study sample was a group of treatment-resistant MDD patients suffering from a severe form of

depression, therefore limiting the generalisability of results.

Uebelacker,

Tremont,

Gillette, Epstein-

Lubow, Strong,

Abrantes et al.

(2017)

RCT N = 122 I = Hatha yoga +

antidepressant medication

(n = 63)

C = Healthy living

workshop +

antidepressant medication

(n = 59)

I = Hatha yoga

- Manualised program

- Introductory individual

meeting with yoga instructor

(20-30 mins)

- Two group yoga classes

offered per week, with the

expectation for participants

to attend at least one class

per week with the option of

attending two per week

- 10 weeks of 80-minute yoga

classes

USA

Individuals with elevated

depression symptoms who

met criteria for MDD based on

SCID; and currently taking

antidepressant at maintained

dose with demonstrated

effectiveness according to

American Psychiatric

Association practice

guidelines

Mean age:

Yoga = 46.78 [12.27]

Control = 47.2 [12.13]

Depressive symptom

severity:

- QIDS

Depressive symptom

severity:

- PHQ-9

Wellbeing:

- SF-20


134

Authors & year







C = Health Living Workshop

(HLW)

- Group HLW used detailed

manual

- Initial individual orientation,

meeting with instructor

- Participants were invited to

attend at least one and up to

two HLW class

- 10 weeks of 60-minute HLW

classes in total

Female gender:

Yoga = 86%

Control = 83%

The RCT examined the effectiveness of weekly yoga classes versus HLW in individuals with elevated depression symptoms who were currently using antidepressant medication. Follow up assessments

took place 3 and 6 months after the intervention.

The primary outcome was depression symptom severity, at post-treatment, no statistical significant difference between groups in depression symptoms was observed (b=-0.82, p=0.36). Over the entire

intervention and at 3-month and 6-month follow up, when controlling for baseline, the yoga group showed lower levels of depression than the HLW group (b=-1.38, p=0.02). At 6-month follow-up, 51% of

yoga participants demonstrated a greater than 50% reduction in depression symptoms, compared to 31% of HLW participants (OR=2.31; p=0.04).

Although there was no significant differences in depression symptoms at the end of the intervention period, yoga participants showed fewer depression symptoms over the entire follow-up period,

suggesting that the benefits of yoga may accumulate over time.

No serious adverse events related to the study procedures were reported. The study sample was predominantly female and white, this may limit the generalisability of the study findings.

Adjunct group yoga for depression (compared to non-active comparison)

Niemi, Kiel,

Allebeck, &

Hoan (2016)

Cluster-

randomised

controlled trial

N = 56 I = Yoga +

Psychoeducation

(n = 34)

C = TAU

(n = 22)

I = The yoga course lasted 8

weeks with one session per

week, using the MANAS manual

in a group setting. The yoga

course include some components

derived from Qigong.

Patients also received 8-week

course of psychoeducation in a

group setting

Vietnam

Patients classified as

moderately and severely

depressed through the PHQ-9

questionnaire (PHQ-9 score

>9), were also diagnosed by

trained general doctor

according to the ICD-10 and

DSM-IV criteria using MINI

Depressive symptom

severity:

- PHQ-9

N/R


135

Authors & year







C = Provided with TAU Median age (Age range):

Yoga = 63 (56-69.5)

Control = 64.5 (58-69)

Female gender:

Yoga = 38%

Control = 50%

This cluster-randomised controlled trial evaluated the effectiveness of a community-based intervention including psychoeducation and yoga for depression management at the primary healthcare level in

one district in Ha Nam province in Vietnam. The study participants were recruited from 21 community health centres and a district hospital, using a cluster randomisation, with 10 communes randomised to

the intervention group and 11 communes randomised to comparison group. Eligible participants were classified as moderately and severely depressed through the PHQ-9 questionnaire (PHQ-9 score >9),

and were also diagnosed by trained doctor according to the ICD-10 and DSM-IV criteria using MINI.

Both groups had similar PHQ-9 scores at baseline (p = 0.91). The intervention group had on average significantly lower PHQ-9 scores after the intervention than the comparison group (p <0.001) at post-

treatment. Almost half of the patients in the intervention group recovered from depression (43%), whereas no one from the comparison group had lost their depression diagnosis as measured by PHQ-9

(0%) after 8 weeks of treatment.

No adverse events were reported. The study had a relatively small sample size and hence may be underpowered. The weak randomisation procedure resulted in an unequal number of participants in the

intervention and comparison arms. In addition, there was only a single outcome measure (PHQ-9), potentially reducing the reliability of the findings.

Adjunct individual yoga for depression


Adjunct group yoga for anxiety


Adjunct individual yoga for anxiety


Adjunct group yoga for depression and anxiety



136

Authors & year







Adjunct individual yoga for depression and anxiety


Adjunct group yoga for AUD (compared to active comparison)

Hallgren,

Romberg,

Bakshi, &

Andreasson

(2014)

Pilot RCT,

feasibility study

N = 18 I = Yoga plus TAU

(n = 9)

C = TAU

(n = 9)

I = Yoga classes combined

breathing techniques, yoga

postures (light physical exercise),

meditation, and deep relaxation.

- 10 weekly group yoga

sessions (1.5 hours each)

- Participants were also

encouraged to practice yoga

at home once per day

- In addition to yoga,

participants also received

standard treatment which

typically include

psychotherapeutic

interventions (CBT and/or

motivational interviewing)

with appropriate

pharmacological

interventions

C = TAU = Psychological and

pharmacological interventions for

alcohol dependence. These were

individual counselling sessions

with a CBT and/or motivational

interviewing focus, typically one

hour per week conducted with a

medical doctor or psychologist,

and the prescription of medication

Sweden

Participants were diagnosed

with AD according to the

DSM-IV criteria

Age and gender information

were not reported, however

the inclusion criteria included

being over 18 years of age,

and both males and females

were invited to participate

Alcohol consumption:

- Timeline follow-back

(TLFB) method

Alcohol dependence:

- DSM-IV criteria for

alcohol dependence

- SADD

Depression and anxiety:

- HADS

Health related quality of

life:

- SDS

Stress:

- PSS

- Saliva cortisol


137

Authors & year







for alcohol dependence (AD) as

required

This study examined the adjunct use of 10 weeks of yoga with TAU for changes in alcohol consumption, affective symptoms, quality of life, and stress. Alcohol-dependent participants were recruited from

an outpatient alcohol treatment clinic in Stockholm, Sweden.

Assessments were taken at baseline and six-month follow-up. Two participants withdrew from the treatment for personal reasons, and two additional participants could not be reached for follow-up.

Therefore the analyses included 14 participants (eight TAU plus yoga, and six TAU alone). Both groups improved from baseline to six-month follow-up on all measures, however improvements were not

significantly different between the groups (All Ps >0.10). This suggests that adding yoga to TAU was no more effective in reducing alcohol consumption, alcohol dependence, and stress, and improving

mood and quality of life, than TAU alone. The study suffered from limited statistical power due to a very small sample size.

ADJUNCT MINDFULNESS

Adjunct group mindfulness for PTSD (compared to active comparison)

Jasbi, Sadeghi

Bahmani,

Karami,

Omidbeygi,

Peyravi, Panahi,

Mirzaee,

Holsboer-

Trachsler,

Brand

(2018)

RCT N = 48 I = MBCT + medication

treatment with SSRI

(Citalopram)

(n = 24)

C = Socio-Therapeutic

Events (STE) +

medication treatment with

SSRI (Citalopram)

(n = 24)

I = MBCT

- Eight weekly group sessions

lasting for 60-70 minutes

- Group size = 7-12

C = Socio-therapeutic group

events

- Eight weekly socio-

therapeutic group events

such as sharing their daily

life experiences, playing

board games, undertaking

short trips in the immediate

countryside, checking

medication adherence and

checking blood pressure

- Socio-therapeutic group

events lasted between 70

minutes to 3 hours

- Group size = 6-12

Iran

Outpatient military veterans

diagnosed with PTSD based

on DSM-5; and PTSD is due

to war experience during the

Iraq-Iran war

Mean age:

MBCT = 53.03 [2.45]

STE = 52.91 [2.91]

Female gender:

0%

PTSD symptom severity:

- PCL-5

Symptoms of depression,

anxiety and stress:

- DASS


138

Authors & year







Standard treatment for all patients

consisted of citalopram (30-50

mg/day at therapeutic dosages)

This RCT explored the effectiveness of MBCT vs socio-therapeutic events as an add-on to standard treatment with citalopram. 48 male outpatient military veterans diagnosed with PTSD were recruited

from a psychiatric hospital in Tehran in Iran.

Assessments were taken at pre- and post-treatment. The primary outcome of the study was PTSD symptom severity using the PCL-5, reporting on four subscales; re-experiencing, avoidance, negative

mood and cognition, and hyperarousal. The study results indicated PTSD symptom severity measured by PCL-5 was lowered when compared to baseline in both treatment conditions, with the MBCT group

exhibiting greater mean differences from pre- to post-treatment than the comparison group (All ps <0.01 for all PCL-5 subscales). Measures of depression, anxiety and stress yielded similar results, with

both treatments arms showing reduction in DASS scores at post-treatment compared to baseline (All ps <0.01 for all DASS subscales), but the MBCT group had a greater effect size than the comparison

group. At post-treatment, comparing the intervention to the comparison, all PCL-5 subscales exhibited large effect sizes (Re-experiencing the events: d = 1.70; Negative mood and cognitive: d = 4.21;

hyperarousal: d = 2.56), with the exception of avoidance subscale (d = 0.69), exhibiting only a medium effect size. For the DASS scores, all subscales had a large effect size (depression: d = 2.15; anxiety:

d = 1.47; stress: d = 3.26) at post-treatment between the two groups. The data suggest that MBCT is an effective intervention as an adjunct to standard Selective Serotonin reuptake inhibitor (SSRI)

medication in reducing symptoms of PTSD, depression, anxiety and stress among veterans.

No adverse events were reported. There were several limitations of the study including a relatively small sample size which limited the statistical power. The study participants were all male therefore

reducing the generalisability of the results. In addition, all outcome measures relied on self-report entirely, using experts’ rating may have made the data more robust. The present study did not collect any

follow-up data, and therefore the long-term effectiveness of MBCT as an add-on cannot be determined.

Adjunct individual mindfulness for PTSD


Adjunct group mindfulness for depression (compared to active comparison)

Eisendrath,

Gillung,

Delucchi,

Segal, Nelson,

McInnes,

Mathalon,

Feldman

(2016)

RCT N = 173 I = MBCT + TAU

Pharmacotherapy

(n = 87)

C = Health-Enhancement

Program (HEP) + TAU

Pharmacotherapy

(n = 86)

I = MBCT with modifications for

Treatment Resistant Depression

(TRD)


sessions + 45 minutes

homework 6 days per week

- Group size = 6-12

USA

Patients satisfying the DSM-

IV diagnostic criteria for

unipolar MDD, and taking

antidepressant medications

with evidence of two or more

adequate trials prescribed

during the current episode

assessed with the

Antidepressant Treatment

History Form (ATHF)

Depressive symptoms

severity:

- HAMD17

Depression treatment

response

and remission:

- HAMD17

Mindfulness:

- FFMQ


139

Authors & year







C = HEP with modifications for

TRD, included discussion on

mood, aerobic exercise, music

therapy, dietary education and

functional movement


sessions + 45 minutes

homework 6 days per week

- Group size = 6-12

Participants in both conditions

were asked to continue their

antidepressant treatment

Mean age:

MBCT = 47.1 [13.46]

HEP = 45.2 [11.19]

Female gender:

MBCT = 76%

HEP = 77%

This single site, RCT compared 8-week courses of MBCT vs Health-Enhancement Program (HEP) as adjuncts to pharmacotherapy. Participants were recruited from outpatient psychiatry and general

medicine clinics, an outpatient psychiatry clinic and from the community. At the end of 8-week treatment, a multivariate analysis showed that relative to the HEP condition, the MBCT condition was

associated with a significantly greater mean percent reduction on the HAM-D17 (37% versus 25%; p=0.01) and a significantly higher rate of treatment responders (30% versus 15%; p=0.03). Although

numerically superior for MBCT than for HEP, the rates of remission did not significantly differ between treatments (22% versus 14%; p=0.15).

One limitation of the study included that the two interventions were delivered by two different sets of instructors.

Huijbers,

Spinhoven,

Spijker, Ruhe,

van Schaik, van

Oppen, Nolen,

Ormel, Kuyken

et. al.

(2015)

RCT N = 68

I = MBCT + mADM

(n = 33)

C = mADM alone

(n = 35)

I = MBCT


sessions

- One day of silent practice

between the 6th and 7th

session

- Participants were

encouraged to practise

meditation at home for about

an hour a day using CDs

- Group size = 8-12

C = Continuing their mADM was

defined as using a therapeutic

dose of mADM at each follow-up

Netherlands

Patients with DSM-IV history

of at least three depressive

episodes

Mean age:

MBCT + mADM = 51.9 [14.4]

mADM = 51.6 [14.2]

Female gender:

MBCT + mADM = 73%

mADM = 71%

Depressive

relapse/recurrence:

- SCID-I

Recurrence and

depression severity:

- Time to

relapse/recurrence

Severity of (residual)

depressive symptoms:

- IDS-C

Quality of life:

- WHOQoL short

version


140

Authors & year







contact during the observed time

period

This randomised controlled trial compared the combination of MBCT and maintenance anti-depressant medication (mADM) to mADM alone on depressive relapse and recurrence in a group of recurrently

depressed patients in remission. Patients were referred by mental health professionals, general practitioners, or recruited via advertisements in the media (TV, magazines, and newspapers). There were no

significant differences in relapse/recurrence rates between the two groups (p=0.95) within the 15 month follow-up period. Results from a survival curve for time to relapse showed that there was no

difference in time to relapse/recurrence between the two conditions (HR=0.87, 95% CI 0.40-1.90, p=0.72). The latent growth curve analysis for severity of residual depressive symptoms over the 15-month

follow-up period showed that patients maintained mild levels of depression throughout the study period, with the course of depression not significantly different between the conditions (p=0.69). There were

no significant differences between the conditions with regard to quality of life.

The results were confounded by the increasing availability of MBCT in the Netherlands, almost a quarter of the individuals who were randomised into the comparison condition decided to participate in

MBCT course elsewhere outside the trial, thus greatly compromised the ITT analyses.

Kuyken, Hayes,

Barrett, Byng,

Dalgleish,

Kessler, Lewis,

Watkins,

Brejcha, Cardy,

Causley,

Cowderoy, et al.

(2015)

RCT N = 424 I = MBCT with support to

taper or discontinue

antidepressant treatment

(MBCT-TS)

(n = 212)

C = mADM

(n = 212)

I = MBCT-TS


sessions

- 4 refresher sessions offered

roughly every 3 months for

the following year

- Patients in the MBCT-TS

group received support to

taper or discontinue their

maintenance

antidepressants

C = mADM

Patients in the maintenance

antidepressant group received

support from their GPs to

maintain a therapeutic-level of

antidepressant medication for the

2-year follow-up period

UK

Patients with a diagnosis of

recurrent major depressive

disorder in full or partial

remission according to the

DSM-IV, with three or more

previous major depressive

episodes. Patients were also

required to be on a

therapeutic dose of

maintenance antidepressant

drugs in line with the British

National Formulary (BNF) and

NICE guidance

Mean age:

MBCT-TS = 50 [12]

mADM = 49 [13]

Female gender:

MBCT-TS = 71%

m-ADM = 82%

Time to relapse/recurrence

of depression:

- SCID

Number of depression free

days:

- SCID

Residual depressive

symptoms severity:

- GRID-HAMD

- BDI-21

Quality of life:

- WHOQOL-BREF

Health-related quality of

life:

- EQ-5D-3L


141

Authors & year







This is a single-blind, parallel randomised controlled trial, involving adult patients (N = 424) with three or more previous major depressive episodes who were taking a therapeutic dose of maintenance

antidepressants. Participants were recruited from general practices in urban and rural settings in four UK centres. The time to relapse or recurrence of depression did not differ between MBCT-TS and

mADM over 24 months (HR = 0.89, 95% CI 0.67–1.18; p=0.43). No significant differences were observed between the two groups in depression-free days, residual depressive symptoms (as measured by

the BDI and GRID-HAMD) over the follow-up period. Non-significance for a difference in quality of life between groups (p = 0.07).

The study sample consisted of a group of individuals who were currently taking antidepressants and were considered a high risk of depressive relapse or recurrence, therefore the study results may not be

generalisable to most people with depression. A total of ten serious adverse events were reported, four of which resulted in death. However the trial steering committee concluded that these adverse events

were not attributable to the intervention or the trial.

Adjunct mindfulness for anxiety


Adjunct mindfulness for AUD


N.B.:

AD = Alcohol Dependence; ATHF = Antidepressant Treatment History Form; BAI = The Beck Anxiety Inventory; BDI = The Beck Depression Inventory ; BNF = British National Formulary; CAPS =

Clinician Administered PTSD Scale; CD-RISC2 = Connor-Davidson Resilience Scale; DASS-21 = Depression Anxiety Stress Scale; DTS = Davidson Trauma Scale; EQ-5D-3L = EuroQol 5

dimensions 3 levels; ESC = Escitalopram; FFMQ = Five Facet Mindfulness Questionnaire; HADS = the Hospital Anxiety and Depression Scale; HAMD-21 = Hamilton Depression Rating Scale (21

items); HEP = Health Enhancement Program; HDRS-17 = Hamilton Rating Scale for Depression; HLW = Healthy Living Workshop; HR = Hazard Ratio; IDS-C = Inventory of Depressive

Symptomatology; mADM = Maintenance Anti-depressant medication; MBCT = Mindfulness-Based Cognitive Therapy; MBCT-TS = Mindfulness-Based Cognitive Therapy with support to taper or

discontinued antidepressant treatment; MDD = Major Depressive Disorder; NICE = National Institute for Health and Care Excellence; OR = Odds Ratio; PHQ-9 = Patient Health Questionnaire; PSS

= Perceived Stress Scale; QIDS = Quick Inventory of Depressive Symptomatology; QXR = Quetiapine fumarate extended release; SADD = Short Alcohol Dependence Data questionnaire; SCID =

Structured Clinical Interview for DSM-5; SDS = Sheehan Disability Scale; SF12 = Short-Form Healthy Survey; SKY = Sudarshan Kriya Yoga; SSRI = Selective Serotonin Reuptake Inhibitor; TAU =

Treatment as usual; TRD = Treatment Resistant Depression; WHOQOL-BREF = World Health Organization Quality of Life


142

Appendix 5

Evaluation of the evidence

Type of Intervention Included Studies

Supported

Promising

Group yoga (stand-alone) for depression

(compared to a non-active comparison)

Six original trials plus one follow-up

paper

Prathikanti et al. (2017)

Chu, Wu, Lin, Chang, Lin, and Yang (2017)

Buttner, Brock, O’Hara, and Stuart (2015)

Field, Diego, Medina, Delgado, and Hernandez

(2012)

Kinser, Bourguignon, Whaley, Hauenstein, and

Taylor (2013)

Kinser, Elswick, and Kornstein (2014) (follow-up

paper)

Uebelacker, Battle, Sutton, Magee, and Miller

(2016)

Group mindfulness (stand-alone) for

depression

Three original trials

Michalak, Schultze, Heidenreich, Schramm (2015)

Shallcross et al. (2015)

Williams et al. (2014)


anxiety (compared to an active

comparison)

Five original trials

Arch, Ayers, Baker, Almklov, Dean and Craske

(2013)

Goldin, Morrison, Jazaieri, Brozovich, Heimberg,

Gross (2016)

Hoge et al. (2013)

Kocovski, Fleming, Hawley, Huta, Antony (2013)

Wong et al. (2016)

Unknown

Group meditation, using mantram

repetition (stand-alone) for PTSD

(compared to non-active comparison)

One original trial

Bormann, Thorp, Wetherell, Golshan, and Lang

(2013)


143

Group meditation (stand-

alone(transcendental meditation) for PTSD

(compared to active comparison)

One original trial

Nidich et al. (2018)

Individual meditation, using mantram

repetition (stand-alone) for PTSD

(compared to an active comparison)

One original trial

Bormann et al. (2018)

Group meditation (stand-aloneautomatic

self-transcending meditation) for

depression (compared to a non-active

comparison)

One original trial

Vasudev et al. (2016)

Group yoga (stand-alone) for PTSD

(compared to a non-active comparison)

Five original trials plus one secondary

analysis

Mitchell et al. (2014)

Reddy, Dick, Gerber, and Mitchell (2014)

(secondary analysis of Mitchell et al., 2014)

Jindani, Turner, and Khalsa (2015)

Quinones, Maquet, Velez, and Lopez (2015)

Reinhardt et al. (2018)

Seppala et al. (2014)

Individual yoga (stand-alone sukha

pranayama yoga for anxiety (compared to

a non-active comparison)

One original trial

Bidgoli, Taghadosi, Gilasi, and Farokhian (2016)

Group yoga (stand-alone) for combined

depression and anxiety (compared to a

non-active comparison)

Four original trials

Davis, Goodman, Leiferman, Taylor, and Dimidjian

(2015)

Falsafi (2016)

Kuvacic, Fratini, Padulo, Iacono, and Giorgio

(2018)

Rani, Tiwari, Singh, and Srivastava (2012)

Individual yoga (stand-alone) for combined

depression and anxiety (compared to a

non-active comparison)

One original trial

de Manincor, Bensoussan, Smith, Barr,

Schweickle, Donoghoe et al. (2016)

Group yoga (stand-alone hatha yoga) for

AUD (compared to a non-active

comparison)

One original trial

Bichler et al. (2017)

Group yoga/meditation (stand-alone) for

depression (compared to a non-active

comparison)

One original trial

Tolahunase, Sagar, Faiq, & Dada (2018)


144

Group mindfulness (stand-alone) for PTSD

Two original trials

Polusny et al. (2015)

Possemato, Bergen-Cico, Treatman, Allen, Wade,

Pigeon (2016)

Individual mindfulness (stand-alone) for

depression

One original trial

Tovote et al. (2014)


combined depression and anxiety

One original trial

Sundquist et al. (2015)

Group mindfulness (stand-alone) for AUD


Garland, Roberts-Lewis, Tronnier, Graves, Kelley

(2016)

Garland, Gaylord, Boettiger, Howard (2010)

Zgierska et al. (2017)

Group yoga (adjunct to

psychopharmacological treatment) for

PTSD (compared to an active comparison)

One original trial

van der Kolk et al. (2014)

Group yoga (adjunct to pharmacological

treatment) for depression (compared to an

active comparison)


Sarubin et al (2014)

Sharma, Barrett, Cucchiara, Gooneratne, Thase

(2017)

Uebelacker et al. (2017)

Group yoga (adjunct to psychoeducation)

for depression (compared to a non-active

comparison)

One original trial

Niemi, Kiel, Allebeck, Hoan (2016)

Group yoga (adjunct to psychological and

pharmacological treatment) for AUD


One original trial

Hallgren, Romberg, Bakshi, Andreasson (2014)

Group mindfulness (MBCT adjunct to

pharmacological treatment) for PTSD


One original trial

Jasbi et al. (2018)

Group mindfulness (adjunct) for

depression (compared to an active

comparison


Eisendrath et al. (2016)

Huijbers et al. (2015)

Kuyken et al. (2015)


145

Appendix 6

Description of mindfulness-based interventions program

curricula

Mindfulness-Based Stress Reduction (MBSR)161

A group program which combines training in mindfulness skills, developed for

populations with a wide range of chronic pain and stress-related disorders.14

Program structure: One orientation session, eight weekly sessions, and one all-day

silent retreat.

Each weekly session covers a different theme based on the mindfulness tenets

including non-judging, non-striving, acceptance, letting go, patience, trust, and non-

centring. Each session also trains participants in mindfulness exercises including

standing yoga stretches, mindfulness breathing, body scan meditation, raisin eating

exercise, eating meditation, sitting meditation, silence, and Aikido-based ‘pushing

exercises’.

Mindfulness-Based Cognitive Therapy (MBCT)22

The overarching aim of MBCT is to help people who have suffered from depression in

the past to learn skills to help prevent depression relapse. The core skill that the MBCT

program aims to teach is “the ability, at times of potential relapse, to recognise and

disengage from mind states characterised by self-perpetuating factors of ruminative,

negative thoughts”.22

Program structure: One initial assessment interview and eight weekly sessions.

Each weekly session covers a different mindfulness theme, and contains exercises

including raisin exercise, body scan exercise, recorded meditations, sitting meditation,

mindfulness of the breath, mindful movement, mindful walking, and marble, stone, or

bread meditation.

Mindfulness-Oriented Recovery Enhancement (MORE)23

A mindfulness intervention adapted from MBCT and tailored to apply mindfulness

principles to addiction-related topics.

MORE was designed to disrupt cognitive, affective, and physiological risk mechanisms

implicated in stress-precipitated relapse to alcohol consumption.

Program structure: A 10-session structured program including the mindfulness

techniques of mindful breathing, body scan, mindful decentring, mindfulness of

craving, mindful walking, compassion meditation, and imaginal rehearsal of mindful

relapse prevention.


Mindfulness

146

-Based Relapse Prevention for Addictive Behaviours (MBRP)24

An integration of standard cognitive behavioural-based relapse prevention treatment

with mindfulness meditation practices.

The program is informed by MBSR, MBCT and Daley and Marlatt’s162 relapse

prevention protocol.

Program structure: A structured protocol of eight, two-hour sessions, each including

formal mindfulness practices and exercises and skills designed to bring the practices

to daily life, specifically into situations in which an individual is at high risk for relapse.

Formal mindfulness practices include body scan, mindful movement, sitting meditation,

walking meditation, and mountain meditation.

Mindfulness-Based Relapse Prevention for Alcohol Dependence (MBRP-A)143

A program designed to prevent relapse for alcohol dependence.

Program structure: Eight-week structured program comprising themes such as

automatic pilot and relapse, awareness of triggers and cravings, mindfulness in daily

life, self-care and life balance, and building support networks.

Mindfulness techniques taught during the program include the raisin exercise, breath

meditation, body scan, mindful hearing or seeing, sitting meditation, mindful walking,

and loving kindness meditation.

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